Sensibilidad y especificidad de la presión de pulso ampliada como prueba diagnóstica de IRC estadio K/DOQI III-b / Sensitivity and specificity of increased pulse pressure as a diagnostic test for K/DOQI III-b

Resumen Introducción: La presión de pulso ampliada (PPA) se asocia a un filtrado glomerular calculado ≤ 60/mL/minuto/1.73 m2, por lo que puede ser útil como prueba diagnóstica para identificar a personas con insuficiencia renal crónica (IRC) estadio K/DOQI III-b. Objetivo: Determinar la utilidad de la PPA como prueba diagnóstica de IRC estadio K/DOQI III-b. Método: Estudio de prueba diagnóstica que incluyó a pacientes adultos sin comorbilidades, registrados en la Cohorte de Trabajadores de la Salud. Se utilizó la fórmula CKD-EPI para calcular la filtración glomerular. Se determinó la presión de pulso restando la presión arterial diastólica a la presión arterial sistólica. Se calculó sensibilidad, especificidad, valor predictivo positivo, valor predictivo negativo y prevalencia. Se elaboró una curva ROC para determinar el área bajo la curva. Resultados: Se incluyeron 6215 pacientes. Se observó que una PPA ≥ 50 mm Hg tuvo sensibilidad de 74 %, especificidad de 70 %, valor predictivo positivo de 1 %, valor predictivo negativo de 100 % y prevalencia de 1 %. El punto de inflexión en la curva ROC para identificar IRC K/DOQI III-b fue de 0.71. Conclusión: La PPA ≥ 50 mm Hg es útil como prueba diagnóstica para identificar a personas con IRC estadio K/DOQI III-b.

Abstract Introduction: Increased pulse pressure (IPP) is associated an estimated glomerular filtration ≤ 60/mL/min/1.73 m2; thus, it can be useful as a diagnostic test to identify people with K/DOQI stage III-b chronic kidney disease (CKD). Objective: To determine the usefulness of IPP as a diagnostic test for K/DOQI stage III-b CKD. Method: Diagnostic test study that included adult patients without comorbidities, registered in the Health Workers Cohort. The CKD-EPI formula was used to calculate glomerular filtration. Pulse pressure was determined by subtracting diastolic from systolic blood pressure. Sensitivity, specificity, positive predictive value, negative predictive value and prevalence were calculated using standard formulas. A ROC curve was generated to determine the area under the curve. Results: A total of 6,215 patients were included. An IPP ≥ 50 mmHg was observed to have a sensitivity of 74 %, specificity of 70 %, positive predictive value of 1 %, negative predictive value of 100 % and a prevalence of 1 %. The inflection point in the ROC curve to identify K/DOQI III-b CKD was 0.71. Conclusion: An IPP ≥ 50 mmHg is useful as a diagnostic test to identify people with K/DOQI stage III-b CKD.

Usefulness of Kidney Donor Profile Index (KDPI) to predict graft survival in a South Brazilian Cohort / Utilidade do Índice de Perfil de Doadores de Rins (KDPI) para prever a sobrevida do enxerto em uma coorte do Sul do Brasil

Abstract Introduction: Kidney Donor Profile Index (KDPI) has been incorporated in the United States to improve the kidney transplant allocation system. Objectives: To evaluate deceased kidney donors' profile using KDPI and compare to the previous United Network for Organ Sharing (UNOS) definition of expanded criteria donors (ECD) and assess the KDPI applicability to predict five-year graft survival and renal function in our sample. Methods: Retrospective cohort of 589 kidney transplants from deceased donors performed from January 2009 to May 2013 with follow-up until May 2018. Results: In 589 kidney transplants, 36.6% of donors were classified as ECD and 28.8% had KDPI ≥ 85%. Mean KDPI was 63.1 (95%CI: 60.8-65.3). There was an overlap of standard and ECD in KDPI between 60 and 95 and a significantly lower death-censored graft survival in KDPI ≥ 85% (78.6%); KDPI 0-20: 89.8%, KDPI 21-59: 91.6%, and KDPI 60-84: 83.0%; p = 0.006. The AUC-ROC was 0.577 (95%CI: 0.514-0.641; p = 0.027). Renal function at 5 years was significantly lower according to the incremental KDPI (p < 0.002). KDPI (HR 1.011; 95%CI 1.001-1.020; p = 0.008), donor-specific antibodies (HR 2.77; 95%CI 1.69-4.54; p < 0.001), acute rejection episode (HR 1.73; 95%CI 1.04-2.86; p = 0.034) were independent and significant risk factors for death-censored graft loss at 5 years. Conclusion: In our study, 36.6% were classified as ECD and 28.8% had KDPI ≥ 85%. KDPI score showed a moderate power to predict graft survival at 5 years. Renal function was significantly lower in patients with higher KDPI.

Resumo Introdução: O Índice de Perfil de Doadores de Rins (KDPI) foi adotado nos Estados Unidos para melhorar o sistema de alocação de transplantes renais. Objetivos: avaliar o perfil dos doadores de rim falecidos usando o KDPI e comparar com a definição anterior do United Network for Organ Sharing (UNOS) de doadores de critérios expandidos (DCE) e avaliar a aplicabilidade do KDPI para prever a sobrevida do enxerto em cinco anos e a função renal em nossa amostra. Métodos: Coorte retrospectiva de 589 transplantes renais de doadores falecidos, realizada de janeiro de 2009 a maio de 2013, com acompanhamento até maio de 2018. Resultados: Em 589 transplantes renais, 36,6% dos doadores foram classificados como DCE e 28,8% apresentaram KDPI ≥ 85%. O KDPI médio foi de 63,1 (IC 95%: 60,8-65,3). Houve uma sobreposição de padrão e DCE no KDPI entre 60 e 95 e uma sobrevida do enxerto censurada por óbito significativamente menor no KDPI ≥ 85% (78,6%); KDPI 0-20: 89,8%, KDPI 21-59: 91,6% e KDPI 60-84: 83,0%; p = 0,006. A ASC-ROC foi de 0,577 (IC 95%: 0,514-0,641; p = 0,027). A função renal aos 5 anos foi significativamente menor de acordo com o aumento do KDPI (p <0,002). KDPI (HR 1.011; 95% CI 1.001-1.020; p = 0.008), anticorpos específicos contra doadores (HR 2,77; 95% CI 1,69-4,54; p <0,001), episódio de rejeição aguda (HR 1,73; 95% CI 1,04-2,86; p = 0,034) foram fatores de risco independentes e significativos para perda do enxerto censurada por óbito em 5 anos. Conclusão: Em nosso estudo, 36,6% foram classificados como DCE e 28,8% apresentaram KDPI ≥ 85%. O escore KDPI mostrou potencial moderado para prever a sobrevida do enxerto em 5 anos. A função renal foi significativamente menor nos pacientes com maior KDPI.

Hepatitis C in Hemodialysis Units: diagnosis and therapeutic approach / Hepatite C nas Unidades de Hemodiálise: diagnóstico e abordagem terapêutica

Abstract According to data from the last census of the Brazilian Society of Nephrology (SBN), the prevalence of hepatitis C virus (HCV) in Brazilian hemodialysis units (HU) is 3.3%, about three times higher than what is reported for the Brazilian general population. Often, professionals working in HU are faced with clinical situations that require rapid HCV diagnosis in order to avoid horizontal transmission within the units. On the other hand, thanks to the development of new antiviral drugs, the cure of patients with HCV, both in the general population and in patients with chronic kidney disease and the disease eradication, appear to be very feasible objectives to be achieved in the near future . In this scenario, SBN and the Brazilian Society of Hepatology present in this review article a proposal to approach HCV within HUs.

Resumo De acordo com os dados do último censo da Sociedade Brasileira de Nefrologia (SBN), a prevalência de portadores do vírus da hepatite C (HCV) nas unidades de hemodiálise (UH) no Brasil é de 3,3%, cerca de três vezes maior do que é observado na população geral brasileira. Muitas vezes, os profissionais que trabalham nas UH deparam-se com situações clínicas que demandam rápido diagnóstico do HCV, a fim de evitar uma transmissão horizontal dentro das unidades. Por outro lado, a cura dos pacientes portadores do HCV, tanto na população geral como na portadora de doença renal crônica e a erradicação da doença, em virtude do desenvolvimento de novas drogas antivirais, parecem ser objetivos bastante factíveis, a ser alcançados em futuro próximo. Nesse cenário, a SBN e a Sociedade Brasileira de Hepatologia apresentam neste artigo de revisão uma proposta de abordagem do HCV dentro das UH.

Zinc alpha 2 glycoprotein as an early biomarker of diabetic nephropathy in patients with type 2 diabetes mellitus / Zinco-alfa2-glicoproteina (ZAG) como biomarcador precoce de nefropatia diabética em pacientes com diabetes mellitus tipo 2

Abstract Introduction: Although microalbuminuria remains the gold standard for early detection of diabetic nephropathy (DN), it is not a sufficiently accurate predictor of DN risk. Thus, new biomarkers that would help to predict DN risk earlier and possibly prevent the occurrence of end-stage kidney disease are being investigated. Objective: To investigate the role of zinc-alpha-2-glycoprotein (ZAG) as an early marker of DN in type 2 diabetic (T2DM) patients. Methods: 88 persons were included and classified into 4 groups: Control group (group I), composed of normal healthy volunteers, and three patient groups with type 2 diabetes mellitus divided into: normo-albuminuria group (group II), subdivided into normal eGFR subgroup and increased eGFR subgroup > 120 mL/min/1.73m2), microalbuminuria group (group III), and macroalbuminuria group (group IV). All subjects were submitted to urine analysis, blood glucose levels, HbA1c, liver function tests, serum creatinine, uric acid, lipid profile and calculation of eGFR, urinary albumin creatinine ratio (UACR), and measurement of urinary and serum ZAG. Results: The levels of serum and urine ZAG were higher in patients with T2DM compared to control subjects and a statistically significant difference among studied groups regarding serum and urinary ZAG was found. Urine ZAG levels were positively correlated with UACR. Both ZAG levels were negatively correlated with eGFR. Urine ZAG levels in the eGFR ˃ 120 mL/min/1.73m2 subgroup were higher than that in the normal eGFR subgroup. Conclusion: These findings suggest that urine and serum ZAG might be useful as early biomarkers for detection of DN in T2DM patients, detectable earlier than microalbuminuria.

Resumo Introdução: Embora a microalbuminúria continue sendo o padrão ouro para a detecção precoce da nefropatia diabética (ND), ela não é um preditor suficientemente preciso do risco de ND. Assim, novos biomarcadores para prever mais precocemente o risco de ND e possivelmente evitar a ocorrência de doença renal terminal estão sendo investigados. Objetivo: Investigar a zinco-alfa2-glicoproteína (ZAG) como marcador precoce de ND em pacientes com debates mellitus tipo 2 (DM2). Métodos: Os 88 indivíduos incluídos foram divididos em quatro grupos: grupo controle (Grupo I), composto por voluntários saudáveis normais; e três grupos de pacientes com DM2 assim divididos: grupo normoalbuminúria (Grupo II), subdivididos em TFG normal e TFG > 120 mL/min/1,73 m2), grupo microalbuminúria (Grupo III) e grupo macroalbuminúria (Grupo IV). Todos foram submetidos a urinálise e exames para determinar glicemia, HbA1c, função hepática, creatinina sérica, ácido úrico, perfil lipídico, cálculo da TFG, relação albumina/creatinina (RAC) e dosagem urinária e sérica de ZAG. Resultados: Os níveis séricos e urinários de ZAG foram mais elevados nos pacientes com DM2 em comparação aos controles. Foi identificada diferença estatisticamente significativa entre os grupos estudados em relação aos níveis séricos e urinários de ZAG. Os níveis urinários de ZAG foram positivamente correlacionados com a RAC. Ambos os níveis de ZAG foram negativamente correlacionados com TFG. Os níveis urinários de ZAG no subgrupo com TFG ˃ 120 mL/min/1,73m2 foram maiores do que no subgrupo com TFG normal. Conclusão: Constatamos que a ZAG sérica e urinária pode ser um útil biomarcador precoce para detecção de ND em pacientes com DM2, sendo detectável mais precocemente que microalbuminúria.

The natural history of solitary post-nephrectomy kidney in a pediatric population

ABSTRACT Introduction: Children with a solitary post-nephrectomy kidney (SNK) are at potential risk of developing kidney disease later in life. In response to the global decline in the number of nephrons, adaptive mechanisms lead to renal injury. The aim of this study was to determine the prevalence and time of onset of high blood pressure (HBP), proteinuria, glomerular filtration rate (GFR) disruption and renal tubular acidosis (RTA) in children with SNK. Materials and methods: After obtaining the approval from our institution's ethics committee, we reviewed the medical records of patients under 18 years of age who underwent unilateral nephrectomy between January 2005 and December 2015 in three university hospitals. Results: We identified 43 patients, 35 (81.4%) cases of unilateral nephrectomy (UNP) were due to a non-oncologic pathology and Wilm's tumor was identified in 8 (18.6%) cases. In patients with non-oncologic disease, 9.3% developed de novo hypertension, with an average time of onset of 7.1 years, 25% developed proteinuria de novo, with an average time of onset of 2.2 years. For GFR, 21.8% presented deterioration of the GFR in an average time of 3.4 years. Ten (43.5%) patients developed some type of de novo renal injury after UNP. Patients with oncologic disease developed the conditions slowly and none of them developed proteinuria. Conclusions: Taking into account the high rate of long term postoperative renal injury, it can be considered that nephrectomy does not prevent this disease. The follow-up of children with SNK requires a multidisciplinary approach and long-term surveillance to detect renal injury.

Preoperative proteinuria is associated with increased rates of acute kidney injury after partial nephrectomy

ABSTRACT Purpose We investigated the association between preoperative proteinuria and early postoperative renal function after robotic partial nephrectomy (RPN). Patients and Methods We retrospectively reviewed 1121 consecutive RPN cases at a single academic center from 2006 to 2016. Patients without pre-existing CKD (eGFR≥60 mL/min/1.73m2) who had a urinalysis within 1-month prior to RPN were included. The cohort was categorized by the presence or absence of preoperative proteinuria (trace or greater (≥1+) urine dipstick), and groups were compared in terms of clinical and functional outcomes. The incidence of acute kidney injury (AKI) was assessed using RIFLE criteria. Univariate and multivariable models were used to identify factors associated with postoperative AKI. Results Of 947 patients, 97 (10.5%) had preoperative proteinuria. Characteristics associated with preoperative proteinuria included non-white race (p<0.01), preoperative diabetes (p<0.01) and hypertension (HTN) (p<0.01), higher ASA (p<0.01), higher BMI (p<0.01), and higher Charlson score (p<0.01). The incidence of AKI was higher in patients with preoperative proteinuria (10.3% vs. 4.6%, p=0.01). The median eGFR preservation measured within one month after surgery was lower (83.6% vs. 91%, p=0.04) in those with proteinuria; however, there were no significant differences by 3 months after surgery or last follow-up visit. Independent predictors of AKI were high BMI (p<0.01), longer ischemia time (p<0.01), and preoperative proteinuria (p=0.04). Conclusion Preoperative proteinuria by urine dipstick is an independent predictor of postoperative AKI after RPN. This test may be used to identify patients, especially those without overt CKD, who are at increased risk for developing AKI after RPN.

Performance of the equations to estimate the glomerular filtration rate in Mexican patients receiving kidney transplantation / Desempeño de las ecuaciones para estimar la tasa de filtración glomerular en pacientes mexicanos receptores de trasplante renal

Abstract Introduction: The management of kidney transplant recipients requires glomerular filtration rate (GFR) monitoring, which is an indicator of graft primary function and patient survival. Objective: To evaluate the performance of different creatinine or cystatin-based formulas in the estimation of glomerular filtration rate in Mexican patients receiving kidney transplantation. Method: 30 transplant recipients were included, in whom the glomerular filtration rate was measured by means of iothalamate, and was also calculated using seven equations based on cystatin or creatinine. Results: The formula with the best performance was the one proposed by the chronic kidney disease epidemiology collaboration (CKD-EPI), with a bias of −2.4 mL/min/1.73 m2: and an accuracy of 9.6; 96.7 % of patients were within 30 % of the measured GFR. The second best formula was the modification of diet in renal disease (MDRD) equation. Cystatin-based equations showed a poor performance. Conclusions: Our study suggests that, in Mexican patients receiving kidney transplantations, the best equations to estimate GFR are the CKD-EPI and MDRD equations.

Cistatina C: marcador de laboratorio precoz de enfermedad renal en pacientes con depranocitosis / Cystatin C: early laboratory marker of renal disease In sickle cell disease

La enfermedad renal en el paciente con drepanocitosis es una consecuencia de su complejo proceso fisiopatológico, por lo que es importante disponer de un grupo de parámetros de laboratorio que, junto a la evaluación clínica, permita determinar de forma precoz la presencia de esta complicación. La cistatina C ha demostrado ser uno de los parámetros que con mayor exactitud aporta evidencia temprana de daño renal en este grupo de pacientes y al mismo tiempo constituye un posible indicador de pronóstico de gran importancia(AU)

Renal disease in patients with sickle cell disease is a consequence of its complex pathophysiological process, so it is important to have a set of laboratory parameters that, together with the clinical evaluation, allow the early detection of this complication. Cystatin C has been shown to be one of the parameters that provides, with greater accuracy, early evidence of kidney damage in this group of patients and at the same time constitutes a possible indicator of prognosis of great importance(AU)

Dietary intake of non-dialysis chronic kidney disease patients: the PROGREDIR study. A cross-sectional study

ABSTRACT BACKGROUND: Despite evidence that diet is very important in relation to chronic kidney disease (CKD) progression, studies in this field are scarce and have focused only on some specific nutrients. We evaluated the energy, macronutrient and micronutrient intakes and dietary patterns of non-dialysis CKD participants in the PROGREDIR study. DESIGN AND SETTING: Cross-sectional study; CKD cohort, São Paulo, Brazil. METHODS: Baseline data on 454 participants in the PROGREDIR study were analyzed. Dietary intake was evaluated through a food frequency questionnaire. Dietary patterns were derived through principal component analysis. Energy and protein intakes were compared with National Kidney Foundation recommendations. Linear regression analysis was performed between energy and nutrient intakes and estimated glomerular filtration rate (eGFR), and between sociodemographic and clinical variables and dietary patterns. RESULTS: Median energy and protein intakes were 25.0 kcal/kg and 1.1 g/kg, respectively. In linear regression, protein intake (β = -3.67; P = 0.07) was related to eGFR. Three dietary patterns (snack, mixed and traditional) were retained. The snack pattern was directly associated with male gender (β = 0.27; P = 0.006) and inversely with diabetes (β = -0.23; P = 0.02). The traditional pattern was directly associated with male gender (β = 0.27; P = 0.007) and schooling (β = 0.40; P < 0.001) and inversely with age (β = -0.01; P = 0.001) and hypertension (β = -0.34; P = 0.05). CONCLUSIONS: We identified low energy and high protein intake in this population. Protein intake was inversely related to eGFR. Dietary patterns were associated with age, gender, schooling level, hypertension and diabetes.

Abdominal obesity and reduction of glomerular filtration

SUMMARY The objective was to evaluate the association between nutritional status and the glomerular filtration rate (GFR) in remaining quilombolas. Cross-sectional study carried out on 32 remaining quilombola communities in the municipality of Alcântara-MA. The nutritional indicators (IN) used were: body mass index (BMI); Waist circumference (WC); Waist-to-hip ratio (WHR); Waist-to-height ratio (WHtR); conicity index (CI) and estimated visceral adipose tissue (VAT). GFR was estimated from the CKD-EPI creatinine-cystatin C formula. The Shapiro Wilk test was used to evaluate the normality of the quantitative variables. In order to compare the second IN sex, the chi-square test was applied. The Anova or Kruskal-Wallis tests were used to verify the association between IN and GFR. Of the 1,526 remaining quilombolas studied, 89.5% were black or brown, 51.2% were women, 88.6% belonged to economic classes D and E and 61.2% were farmers or fishermen. Clinical investigation revealed 29.2% of hypertensive patients, 8.5% of diabetics and 3.1% with reduced GFR. The BMI revealed 45.6% of the remaining quilombolas with excess weight. When compared to men, women presented a higher prevalence of overweight by BMI (56.6% vs 33.8%, p <0.001) and abdominal obesity CC (52.3% vs 4.3%), WHR (76,5% vs 5.8%), WHtR (82.3% vs 48.9%) and VAT (27.1% vs 14.5%) (p <0.001). Comparing the means of IN according to the GFR, it was observed that the higher the mean value of the IN lower the GFR (p <0.05). The GFR reduced with increasing mean values of nutritional indicators of abdominal obesity, regardless of sex.

RESUMO O objetivo foi avaliar a associação entre o estado nutricional e a taxa de filtração glomerular (TFG) em remanescentes quilombolas. Estudo transversal, realizado em 32 comunidades remanescentes de quilombolas, no município de Alcântara - MA. Os indicadores nutricionais (IN) utilizados foram: índice de massa corporal (IMC); circunferência da cintura (CC); relação cintura-quadril (RCQ); relação cintura-estatura (RCEst); índice de conicidade (Índice C) e tecido adiposo visceral estimado (TAVe). A TFG foi estimada a partir da fórmula do CKD-EPI creatinina-cistatina C. O teste Shapiro Wilk foi utilizado para avaliar a normalidade das variáveis quantitativas. Para comparar os IN segundo sexo foi aplicado o teste qui-quadrado. Os testes Anova ou Kruskal-Wallis foram usados para verificar a associação entre os IN e a TFG. Dos 1.526 remanescentes quilombolas estudados, 89,5% eram da cor preta ou parda, 51,2% eram mulheres, 88,6% pertenciam às classes econômicas D e E e 61,2% eram lavradores ou pescadores. A investigação clínica revelou 29,2% de hipertensos, 8,5% de diabéticos e 3,1% com TFG reduzida. O IMC revelou 45,6% dos remanescentes quilombolas com excesso de peso. Quando comparadas aos homens, as mulheres apresentaram maior prevalência de excesso de peso pelo IMC (56,6% vs. 33,8%; p <0,001) e obesidade abdominal CC (52,3% vs. 4,3%), RCQ (76,5% vs. 5,8%), RCEst (82,3% vs. 48,9%) e TAVe (27,1% vs. 14,5%) (p<0,001). Comparando as médias dos IN segundo a TFG observou-se que, quanto maior o valor médio dos IN, menor a TFG (p<0,05). A TFG foi reduzida com o aumento dos valores médios dos indicadores nutricionais de obesidade abdominal, independentemente do sexo.

Do We Need to Personalize Renal Function Assessment in the Stratification of Patients Undergoing Cardiac Surgery? / É Necessário Personalizar a Avaliação da Função Renal na Estratificação de Pacientes Submetidos à Cirurgia Cardíaca?

Abstract Background: Renal dysfunction is an independent predictor of morbidity and mortality in cardiac surgery. For a better assessment of renal function, calculation of creatinine clearance (CC) may be necessary. Objective: To objectively evaluate whether CC is a better risk predictor than serum creatinine (SC) in patients undergoing cardiac surgery. Methods: Analysis of 3,285 patients registered in a prospective, consecutive and mandatory manner in the Sao Paulo Registry of Cardiovascular Surgery (REPLICCAR) between November 2013 and January 2015. Values of SC, CC (Cockcroft-Gault) and EuroSCORE II were obtained. Association analysis of SC and CC with morbidity and mortality was performed by calibration and discrimination tests. Independent multivariate models with SC and CC were generated by multiple logistic regression to predict morbidity and mortality following cardiac surgery. Results: Despite the association between SC and mortality, it did not calibrate properly the risk groups. There was an association between CC and mortality with good calibration of risk groups. In mortality risk prediction, SC was uncalibrated with values > 1.35 mg /dL (p < 0.001). The ROC curve showed that CC is better than SC in predicting both morbidity and mortality risk. In the multivariate model without CC, SC was the only predictor of morbidity, whereas in the model without SC, CC was not only a mortality predictor, but also the only morbidity predictor. Conclusion: Compared with SC, CC is a better parameter of renal function in risk stratification of patients undergoing cardiac surgery.

Resumo Fundamentos: Disfunção renal é preditor independente de morbimortalidade após cirurgia cardíaca. Para uma melhor avaliação da função renal, o cálculo do clearance de creatinina (CC) pode ser necessário. Objetivo: Avaliar objetivamente se o CC é melhor que a creatinina sérica (CS) para predizer risco nos pacientes submetidos à cirurgia cardíaca. Métodos: Análise em 3285 pacientes do Registro Paulista de Cirurgia Cardiovascular (REPLICCAR) incluídos de forma prospectiva, consecutiva e mandatória entre novembro de 2013 e janeiro de 2015. Foram obtidos valores de CS, CC (Cockcroft-Gault) e do EuroSCORE II. Análise de associações da CS e do CC com morbimortalidade foi realizada mediante testes de calibração e discriminação. Por regressão logística múltipla, foram criados modelos multivariados independentes com CS e com CC para predição de risco de morbimortalidade após cirurgia cardíaca. Resultados: Apesar da associação entre a CS e morbimortalidade, essa não calibrou adequadamente os grupos de risco. Houve associação entre o CC e morbimortalidade com boa calibração dos grupos de risco. Na predição do risco de mortalidade, a CS ficou descalibrada com valores >1,35 mg/dL (p < 0,001). A curva ROC revelou que o CC é superior à CS na predição de risco de morbimortalidade. No modelo multivariado sem CC, a CS foi a única preditora de morbidade, enquanto que no modelo sem a CS, o CC foi preditor de mortalidade e o único preditor de morbidade. Conclusão: Para avaliação da função renal, o CC é superior que a CS na estratificação de risco dos pacientes submetidos a cirurgia cardíaca.

Arterial stiffness and 25-hydroxyvitamin D levels in chronic kidney disease patients

Summary Objective: Arterial stiffness refers to arterial wall rigidity, particularly developing in central vessels. Arterial stiffness increases in early stage chronic kidney disease (CKD), and it is a strong predictor of cardiovascular and all cause mortality. Vitamin D has beneficial effects on blood pressure, vascular endothelial function and arterial stiffness. 25-hydroxyvitamin D (25(OH)D) deficiency is quite common worldwide and in the CKD population. We aimed to evaluate the prevalence of 25(OH)D deficiency and its relation with arterial stiffness in CKD. Method: Our study included 101 patients (51 male, 50 female), with stages 3B-5 CKD not on dialysis. A single-cuff arteriograph device (Mobil-O-Graph) was used to evaluate arterial stiffness parameters of pulse wave velocity (PWV) and augmentation index (Alx@75). The patients were divided into two groups: group I vitamin D non-deficient [25(OH)D > 15 ng/mL] and group II vitamin D deficient [25(OH)D ≤ 15 ng/mL]. Results: Overall, the mean 25(OH)D level was 14.1±7.9 ng/mL and 70 patients (69.4%) were vitamin D deficient. The mean Alx@75 value was significantly higher in group II (28.6±10.8% vs. 23.3±13.5%, p=0.038). PWV was higher in group II, but the difference was not significant. Group II exhibited significantly lower serum albumin (p<0.001), hemoglobin (p=0.005), calcium (p=0.041) and estimated glomerular filtration rate (eGFR) (p=0.041), but significantly higher 24-hour proteinuria (p=0.011) and more females (p=0.006). Vitamin D was negatively correlated with Alx@75 augmentation pressure, parathyroid hormone, proteinuria and body mass index, and positively correlated with albumin, hemoglobin, eGFR, calcium and transferrin. 25(OH)D was independently associated with Alx@75 (beta=-0.469, p=0.001) and albumin (beta=0.447, p=0.002). Conclusion: In CKD patients 25(OH)D deficiency was common, particularly in females. Level of 25(OH)D was independently associated with Alx@75.

Characterization of an experimental model of progressive renal disease in rats

ABSTRACT PURPOSE: To characterize an experimental model of progressive renal disease induced by different degrees of nephrectomy in rats. METHODS: Eighty male Wistar rats were divided into four experimental groups (n=20/group): sham surgery (control group), progressive degrees of nephrectomy leading to mild uremia (group 1), moderate uremia (group 2) and severe uremia (group 3). Ten animals of each group were followed for two or four weeks. At the end, blood and 24-hour urine samples were collected to determine renal function parameters. Urine output and water and food intake were daily monitored. RESULTS: In rats of group 1, serum levels of creatinine and urea and microalbuminuria were increased, while reduced creatinine clearance (p<0.05, compared with control group), without changing blood pressure. Animals of group 2 had more accentuated alterations: increases in urinary output, blood pressure, serum concentrations of urea, creatinine, sodium, potassium, and in microalbuminuria, and reduction of creatinine clearance (p<0.05). Group 3 exhibited even more increased serum concentrations of urea, creatinine, sodium and potassium, blood pressure and microalbuminuria, and decreased creatinine clearance (p<0.05) in comparison with control group and unilateral nephrectomy. CONCLUSION: Progressive nephrectomy in rats seems to be useful to study the physiopathology of chronic kidney disease and its mechanisms of progression.

Evaluation of creatinine-based and cystatin C-based equations for estimation of glomerular filtration rate in type 1 diabetic patients

ABSTRACT Objective Several formulas based in different biomarkers may be used to estimate glomerular filtration rate (GRF). However, all of them have some limitations, and it is very important to evaluate their performances in different groups of patients. Therefore, we compared GFR, as estimated by creatinine-based and cystatin C-based equations, according to albuminuria, in type 1 diabetes (T1DM), in an observational case-control study. Subjects and methods T1DM patients were classified according to albuminuria: normoalbuminuric (n = 63), microalbuminuric (n = 30), macroalbuminuric (n = 32). GFR was calculated using creatinine-based and cystatin C-based (aMDRD, CKD-EPIcr, CKD-EPIcys, MacIsaac, Tan and CKD-EPIcrcys) equations. Spearman Correlation was used to evaluate the correlation of GFR estimated by the formulas with albuminuria. ROC curves were constructed to compare AUCs of GFR estimated by equations, in reference to macroalbuminuria. Sensibility, specificity and accuracy were calculated for a cut-off < 60 mL/min/1.73 m2. Results GFR estimated by creatinine-based and cystatin C-based equations significantly differed among normoalbuminuric, microalbuminuric and macroalbuminuric patients. Spearman correlation and AUCs of GFR estimated by creatinine-based and cystatin C-based formulas were very similar to each other, though cystatin C-based equations presented better correlation with albuminuria and higher AUCs than the creatinine-based ones, and the best accuracy to detect macroalbuminuric patients. Conclusion Although GFR estimated by all creatinine-based and cystatin C-based equations permitted the differentiation between T1DM patients, according to albuminuria, cystatin C-based equations presented best accuracy to detect macroalbuminuria in T1DM patients and should be considered in the clinical routine in order to increase the possibility of early diagnostic of chronic renal disease.

Very Long-Term Prognostic Role of Admission BNP in Non-ST Segment Elevation Acute Coronary Syndrome / Papel Prognóstico a Muito Longo Prazo do BNP de Admissão na Síndrome Coronariana Aguda sem Elevação do Segmento ST

Abstract Background: BNP has been extensively evaluated to determine short- and intermediate-term prognosis in patients with acute coronary syndrome, but its role in long-term mortality is not known. Objective: To determine the very long-term prognostic role of B-type natriuretic peptide (BNP) for all-cause mortality in patients with non-ST segment elevation acute coronary syndrome (NSTEACS). Methods: A cohort of 224 consecutive patients with NSTEACS, prospectively seen in the Emergency Department, had BNP measured on arrival to establish prognosis, and underwent a median 9.34-year follow-up for all-cause mortality. Results: Unstable angina was diagnosed in 52.2%, and non-ST segment elevation myocardial infarction, in 47.8%. Median admission BNP was 81.9 pg/mL (IQ range = 22.2; 225) and mortality rate was correlated with increasing BNP quartiles: 14.3; 16.1; 48.2; and 73.2% (p < 0.0001). ROC curve disclosed 100 pg/mL as the best BNP cut-off value for mortality prediction (area under the curve = 0.789, 95% CI= 0.723-0.854), being a strong predictor of late mortality: BNP < 100 = 17.3% vs. BNP ≥ 100 = 65.0%, RR = 3.76 (95% CI = 2.49-5.63, p < 0.001). On logistic regression analysis, age >72 years (OR = 3.79, 95% CI = 1.62-8.86, p = 0.002), BNP ≥ 100 pg/mL (OR = 6.24, 95% CI = 2.95-13.23, p < 0.001) and estimated glomerular filtration rate (OR = 0.98, 95% CI = 0.97-0.99, p = 0.049) were independent late-mortality predictors. Conclusions: BNP measured at hospital admission in patients with NSTEACS is a strong, independent predictor of very long-term all-cause mortality. This study allows raising the hypothesis that BNP should be measured in all patients with NSTEACS at the index event for long-term risk stratification.

Resumo Fundamento: O BNP foi exaustivamente avaliado para a determinação do prognóstico em curto e médio prazo em pacientes com síndrome coronariana aguda, mas o seu papel para a mortalidade a longo prazo é incerta. Objetivo: Determinar o papel prognóstico a muito longo prazo do peptídeo natriurético do tipo B (BNP) para a mortalidade por todas as causas em pacientes com síndrome coronariana aguda sem supradesnivelamento do segmento ST (SCASSST). Métodos: Coorte de 224 pacientes consecutivos com SCASSST, prospectivamente atendidos no setor de emergência, em que se mediu o BNP na chegada para estabelecer o prognóstico ao longo do seguimento mediano de 9,34 anos para a mortalidade por todas as causas. Resultados: Diagnosticou-se angina instável em 52,2% e infarto do miocárdio sem supradesnivelamento do segmento ST em 47,8%. A mediana do BNP da admissão foi de 81,9 pg/mL (intervalo IQ = 22,2; 225) e a taxa de mortalidade correlacionou-se com quartis crescentes de BNP: 14,3; 16,1; 48,2; e 73,2% (p < 0,0001). A curva ROC revelou 100 pg/mL como o melhor ponto de corte de BNP para a predição de mortalidade (área sob a curva = 0,789, 95% CI = 0,723-0,854) sendo um forte preditor de mortalidade tardia: BNP < 100 = 17,3% vs. BNP ≥ 100 = 65,0%, RR = 3,76 (IC 95% = 2,49-5,63, p < 0,001). Na análise de regressão logística, idade>72 anos (OR = 3,79, IC 95% = 1,62-8,86, p = 0,002), BNP ≥ 100 pg/mL (OR = 6,24, IC 95% = 2,95-13,23, p < 0,001) e taxa de filtração glomerular estimada (OR = 0,98, IC 95% = 0,97-0,99, p = 0,049) foram preditores independentes de mortalidade tardia. Conclusões: O BNP medido na admissão hospitalar em pacientes com SCASSST é um forte preditor independente de mortalidade por todas as causas de muito longo prazo. Este estudo permite que se levante a hipótese de que o BNP deva ser medido em todos os pacientes com SCASSST no evento-índice para a estratificação de risco a longo prazo.

Body mass index and comorbidity are associated with postoperative renal function after nephrectomy

ABSTRACTPurpose:To explore the association of body mass index (BMI) and comorbidity with renal function after nephrectomy.Materials and Methods:We retrospectively analyzed 263 patients submitted to partial or radical nephrectomy from 2000-2013. Variables assessed included BMI, Charlson Comorbidity Index (CCI), race, tobacco use, tumor histology, surgical approach, Fuhrman nuclear grade, and tumor (T) classification. Glomerular filtration rate (GFR) was estimated using the Cockroft-Gault equation, adjusted for gender. Logistic regression was performed and included all interaction terms.Results:Median follow-up was 19.6 months (IQR 5.2, 53.7). Median preoperative GFR was 86.2mL/min/1.73m2 and median postoperative GFR was 68.4mL/min/1.73m2. BMI (OR 1.07, 95%CI 1.02-1.11), CCI (OR 1.19, 95%CI 1.04-1.37), and radical nephrectomy (OR 3.09, 95%CI 1.51-6.33) were significantly associated with a decline in renal function of ≥25%.Conclusion:BMI and CCI are associated with postoperative decline in renal function after nephrectomy. Additionally, radical nephrectomy is significantly associated with decreasing renal function compared to partial nephrectomy. These findings highlight the importance of assessing patient comorbidity in the decision making process for patients presenting with a renal mass.

Predominance of STEMI and severity of coronary artery disease in a cohort of patients hospitalized with acute coronary syndrome: a report from ABC Medical School / Predomínio de infarto agudo do miocárdio com supra ST e gravidade da doença arterial coronariana em uma coorte de pacientes internados com síndrome coronariana aguda: relato da Faculdade de Medicina do ABC.

Summary Introduction: acute coronary syndromes (ACS) represent a widely prevalent health issue with high mortality in Brazil and worldwide. The severity of ACS is not known in patients in the city of São Bernardo do Campo a municipality contiguous and adjacent to the city of São Paulo. Objectives: to study the profile of coronary disease in patients hospitalized with ACS who underwent coronary angiography in the emergency room between 2012 and 2013. Methods: this is an observational study that included consecutive patients with ACS admitted to the emergency room of a hospital. Data collection was performed using medical records with the following variables: sex, age, risk factors for cardiovascular disease, coronary angiography. Results: the sample in this period included 131 patients, of which 64.8% were men. The most prevalent diagnosis was ST-elevation myocardial infarction (STEMI) (57.2%) followed by non-ST-elevation myocardial infarction (NSTEMI) (22.1%) and unstable angina (UA) (20.6%). There were no significant differences in the epidemiology and risk factors between the diagnoses, except that heart failure was more prevalent in patients with UA. Discussion: there were no differences between groups regarding the coronaries involved; however, STEMI patients showed similar numbers of multi- and singlevessel lesions, NSTEMI patients showed more multivessel lesions, and UA patients showed more multivessel lesions or lesion-free arteries. Although multivessel lesions were prevalent in all groups, STEMI patients showed a significantly higher number of single-vessel lesions compared with the other acute coronary syndromes. Conclusion: the study demonstrated a predominance of STEMI in the studied population, which differs from the usual results in ACS. .

Resumo Introdução: a síndrome coronariana aguda (SCA) é uma das principais causas de morbidade e mortalidade no Brasil e no mundo. A gravidade da coronariopatia em pacientes atendidos na cidade de São Bernardo do Campo não é conhecida. Objetivo: estudar o perfil da doença coronariana em pacientes internados com SCA e submetidos à cineangiocoronariografia entre 2012 e 2013. Métodos trata-se de estudo descritivo no qual se incluíram pacientes com SCA admitidos no setor de emergência do hospital. Houve consulta aos prontuários das seguintes variáveis: sexo, idade, fatores de risco para doença cardiovascular, diagnóstico e lesões coronárias. O erro alfa estabelecido foi de 5%. Resultados: a amostra neste período foi de 131 pacientes, sendo 64,8% homens. O diagnóstico mais prevalente foi o infarto agudo do miocárdio com supradesnível do segmento ST (IAMCST) (57,2%), seguido de infarto agudo do miocárdio sem supradesnível do segmento ST (IAMSST) (22,1%) e angina instável (AI) (20,6%). Não houve diferenças significativas quanto ao perfil epidemiológico e a fatores de risco entre os diagnósticos, com exceção da presença de insuficiência cardíaca, mais prevalente nos pacientes com AI. Discussão: as coronárias acometidas não diferiram entre os grupos; porém, enquanto o grupo IAMCST apresentou proporção de lesões multi e uniarteriais similares, o grupo IAMSST apresentou mais lesões multiarteriais, e o grupo AI, mais lesões multiarteriais ou artérias livres de lesões. Apesar das lesões multiarteriais serem prevalentes em todos os grupos, os pacientes com IAMCST apresentaram um número significativamente maior de lesões uniarteriais em comparação a pacientes com outras síndromes coronárias agudas. Conclusão: o estudo demonstrou um predomínio de IAMCST na população estudada, o que difere dos resultados habituais na SCA. .

Estimated glomerular filtration rate in patients with type 2 diabetes mellitus / Estimativa da taxa de filtração glomerular em pacientes com diabetes mellitus tipo 2

Objective: to estimate the glomerular filtration using the Cockcroft-Gault (CG), Modification of Diet in Renal Disease (MDRD), and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations, and serum creatinine in the screening of reduced renal function in patients with type two diabetes (T2DM) enrolled in the Family Health Strategy (ESF, Brazilian federal health-care program). Methods: a cross-sectional descriptive and analytical study was conducted. The protocol consisted of sociodemographics, physical examination and biochemical tests. Renal function was analyzed through serum creatinine and glomerular filtration rate (GFR) estimated according to the CG, MDRD and CKD-EPI equations, available on the websites of the Brazilian Nephrology Society (SBN) and the (NKF). Results: 146 patients aged 60.9±8.9 years were evaluated; 64.4% were women. The prevalence of serum creatinine >1.2 mg/dL was 18.5% and GFR <60 mL/min/1.73m2 totaled 25.3, 36.3 and 34.2% when evaluated by the equations CG, MDRD and CKD-EPI, respectively. Diabetic patients with reduced renal function were older, had long-term T2DM diagnosis, higher systolic blood pressure and higher levels of fasting glucose, compared to diabetics with normal renal function. Creatinine showed strong negative correlation with the glomerular filtration rate estimated using CG, MDRD and CKD-EPI (-0.64, -0.87, -0.89) equations, respectively. Conclusion: the prevalence of individuals with reduced renal function based on serum creatinine was lower, reinforcing the need to follow the recommendations of the SBN and the National Kidney Disease Education Program (NKDEP) in estimating the value of the glomerular filtration rate as a complement to the results of serum creatinine to better assess the renal function of patients. .

Objetivo: estimar a taxa de filtração glomerular por meio das equações Cockcroft e Gault (CG), Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) e da creatinina sérica na triagem da função renal reduzida em pacientes com diabetes mellitus tipo 2 (DM2), adscritos em estratégia de saúde da família (ESF). Métodos: foi realizado um estudo transversal, descritivo e analítico. O protocolo foi constituído de dados sociodemográficos, exame físico e dosagens bioquímicas. A função renal foi analisada pela creatinina sérica e pela taxa de filtração glomerular (TFG) estimada segundo as equações CG, MDRD e CKD-EPI, disponibilizadas nos websites da Sociedade Brasileira de Nefrologia (SBN) e da National Kidney Foundation (NKF). Resultados: foram avaliados 146 pacientes com média de idade de 60,9±8,9 anos; 64,4% eram mulheres. A prevalência de creatinina sérica >1,2 mg/dL foi de 18,5%, e a TFG < 60 mL/min/1,73 m2 foi de 25,3%, 36,3% e 34,2% quando avaliadas pelas equações CG, MDRD e CKD-EPI, respectivamente. Os pacientes diabéticos com função renal reduzida eram idosos, apresentavam maior tempo de diagnóstico de DM2, pressão arterial sistólica mais elevada e níveis superiores de glicemia de jejum, quando comparados a diabéticos com função renal normal. A creatinina apresentou correlação negativa e forte com a taxa de filtração glomerular estimada pelas equações CG, MDRD e CKD-EPI (-0,64; -0,87; -0,89, respectivamente). Conclusão: a prevalência de indivíduos com função renal reduzida a partir dos valores de creatinina sérica foi inferior, reforçando a necessidade de seguir as recomendações da SBN e do National Kidney Disease Education Program (NKDEP) em estimar o valor do ritmo de filtração glomerular como complemento ao resultado da creatinina sérica para melhor avaliar a função renal dos pacientes. .

Alteração de taxa de filtração glomerular em pacientes hipertensos do município de Vitória-ES / Change in glomerular filtration rate in hypertensive patients in Vitória-ES / Cambio en la tasa de filtración glomerular en pacientes hipertensos en Vitória-ES

Como monitorização da função renal, utiliza-se a estimativa da filtração glomerular (FG). Neste estudo, objetivou-se estimar a FG mediante a equação de Cockcroft-Gault em hipertensos atendidos no município de Vitória-ES. Estudo transversal de dados secundários com 754 hipertensos atendidos nas unidades de saúde, em 2009. Para análise estatística, utilizou-se o teste quiquadrado. Predominou o sexo feminino, excesso de peso e pressão arterial não controlada. A média de idade foi de 58,18 anos (±13,52) e da creatinina sérica (CrS) 0,81mg/dl (±0,28). A prevalência da FG reduzida foi de 19% quando de 30 a 59ml/min e 1,6% quando de 29 a 15ml/min; e apresentou-se 15 vezes maior em idosos, 4,93 vezes maior naqueles com CrS elevada, 2,19 vezes nos hipertensos com baixo peso e 1,6 vez mais prevalente em homem. O estudo evidenciou a importância de monitorar a função renal com vistas à intervenção precoce e retardamento da perda da função renal em hipertensos.

As monitoring of renal function, it is used the estimation of glomerular filtration rate (GFR). This study aimed to estimate the GFR by means of the Cockcroft-Gault equation in hypertensive patients in the Municipality of Vitoria-ES. It is a transversal study of secondary data with 754 hypertensive patients attended in health facilities in 2009. For statistical analysis, there has been used the chi-square test. The female sex, overweight and uncontrolled blood pressure predominated. The average age was 58.18 years (± 13.52) and the serum creatinine (SCr) 0.81 mg / dl (± 0.28). The prevalence of reduced GFR was 19% when from 30 to 59 ml/min and 1.6% when from 29 to 15 ml/min. The prevalence of reduced GFR was 15 times higher in the elderly, 4.93 times higher in those with elevated SCr, 2.19 times in low-weight hypertensives and 1.6 times more prevalent in men. The study showed the importance of monitoring renal function with a view to early intervention and postponement of kidney function loss in hypertensive patients.

Para la vigilancia de la función renal, se utiliza estimar la tasa de filtración glomerular (TFG). El objetivo de este estudio fue estimar la FG por la ecuación de Cockcroft-Gault en pacientes hipertensos en Vitória-ES. Estudio transversal, con datos secundarios de 754 pacientes hipertensos, asistidos en los centros de salud del municipio, en 2009. Para análisis estadístico se utilizó el test de chi-cuadrado. Predominaran el sexo femenino, el sobrepeso y la presión arterial sin control. La edad promedio fue de 58,18 años (± 13,52) y la creatinina sérica (CrS) de 0,81 mg / dl (± 0,28). La prevalencia de FG se redujo en 19% cuando 30 a 59ml/min y en 1,6% cuando 29 a 15ml/min, y se presentó 15 veces mayor en los ancianos, 4,93 veces superior en aquellos con niveles elevados de CrS, 2,19 veces en pacientes hipertensos con bajo peso y 1,6 veces más frecuente en los hombres. Esto demuestra la importancia de vigilar la función renal con el fin de una intervención temprana y al retraso de la pérdida de la función renal en pacientes hipertensos.

Correlação entre MCP-1, HbA1c e a filtração glomerular em pacientes não diabéticos / Correlation between MCP-1, HbA1c and glomerular filtration in nondiabetic patients

OBJETIVO: O presente estudo visa testar a possibilidade de que indivíduos não diabéticos, com glicemia de jejum < 126 mg/dL e com HbA1c alterada, já apresentem diminuição na filtração glomerular estimada (FGe) e aumento do MCP-1, em comparação com aqueles com HbA1c normal, independente de outras alterações metabólicas. MATERIAIS E MÉTODOS: Este estudo utilizou dados do Estudo CAMELIA (cardiometabólico renal familiar), de julho de 2006 a dezembro de 2007, com visitas aos módulos do Programa Médico de Família (PMF) de Niterói, RJ. RESULTADOS: Verificamos associação independente entre a alteração da HbA1c (≥ 5,7 e < 6,5% versus < 5,7%) e diminuição da taxa de filtração glomerular estimada. A HbA1c mostrou ser um marcador subclínico de alterações metabólicas em pacientes não diabéticos e com glicemia de jejum < 126 mg/dL, em especial na população de mulheres e de indivíduos com a cor da pele preta. CONCLUSÃO: Essas observações indicam a possibilidade de se utilizar a HbA1c no intuito de se triar grupos de risco, visando propor estratégias de intervenção precoce e, assim, promover a prevenção de doenças crônicas, como diabetes e doença renal crônica.

OBJECTIVE: This study aims investigate if nondiabetic subjects with fasting glucose < 126 mg/dL but altered HbA1c already have lower estimated glomerular filtration (eGFR) and high serum MCP-1 levels in comparison to nondiabetics with normal HbA1c, independent of other metabolic changes. MATERIALS AND METHODS: Data were derived from the database of the CAMELIA (cardio-metabolic-renal family) study, a cross sectional study performed between July 2006 and December 2007, with participants recruited from the Family Doctor Program, Niterói, RJ. RESULTS: An independent association between changes in HbA1c (≥ 5.7 and < 6.5% versus < 5.7%) and decreased eGFR rate was found. The HbA1c was shown to be a marker of metabolic changes in nondiabetic subjects with fasting glucose < 126 mg/dL, particularly in women and blacks. CONCLUSION: These observations support the use of HbA1c levels in strategies for early intervention and prevention of chronic diseases such as diabetes mellitus and chronic kidney disease.