Adherence to antihypertensive medication after referral to secondary healthcare: A prospective cohort study.

BACKGROUND: Nonadherence (NAd) to antihypertensive medication is associated with lack of blood pressure control and worsened long-term outcomes. Increased access to a programme for high-risk cardiovascular patients has the potential to reduce NAd and improve clinical outcomes. We evaluated implementation NAd prevalence and risk factors among severely hypertensive patients after 12-month-long access to secondary healthcare centres. METHODS: The Morisky Green Levine Scale (MGLS) was used to analyse antihypertensive medication NAd in a prospective cohort of 485 patients. Logistic regression models evaluated the influence of ecological model factors on NAd. RESULTS: The majority of patients were female, had low health literacy, a low family income and a mean age of 61.8 ± 12.5 years. Prevalence of NAd fell from 57.1% at programme entry to 28.3% (P < .001) at the end of the study. After access to a secondary healthcare centre, we observed better blood pressure control, an increase in the number of pills/day and a higher number of antihypertensive medications. Predictive variables of NAd were age (OR 1.027; CI 1.003-1.051; P = .023), low health literacy (OR 1.987; CI 1.009-3.913; P = .047), systolic blood pressure (OR 1.010; CI 1.003-1.021; P = .049), dosages ≥ 2 times/day (OR 1.941; CI 1.091-3.451; P = .024) and patient satisfaction with the healthcare team (OR 0.711; IC 0.516-0.980; P = .037). CONCLUSIONS: Greater access to health services is associated with a reduction in NAd to antihypertensive medication and better blood pressure control. NAd was correlated with modifiable variables such as treatment complexity and, for the first time, team satisfaction, suggesting that implementation of similar programmes may limit NAd in similar patient groups.

Chronic kidney disease progression in kidney transplant recipients: A focus on traditional risk factors.

Kidney transplant recipients are a subset of patients with chronic kidney disease (CKD) that remain at high risk for progression to dialysis and mortality. Recent advances in immunosuppression have only partially improved long-term graft and patient survival. Discovery of new immunosuppressive regimens is a slow and resource-intensive process. Hence, recognition and management of modifiable allogeneic and non-allogeneic risk factors for progression to CKD among kidney transplant recipients is of major interest for improving long-term outcomes. Graft survival is mainly determined by the quality of the allograft and by the patient's alloimmune response, which is influenced by human leukocyte antigen matching and the presence of donor-specific antibodies. Alloimmune responses manifest as acute and chronic forms of cell- and antibody-mediated rejection, which can be worsened by patient non-adherence or under-immunosuppression. However, donor and patient ages, glomerular disease recurrence, time on dialysis, pre-existing cardiovascular burden, medication side-effects and traditional risk factors, such as hypertension, proteinuria, anaemia, dyslipidaemia, diabetes and bone mineral disorder, which can ultimately lead to severe endothelial derangement, also contribute to graft loss and mortality. These traditional risk factors, common to pre-dialysis patients, often are considered of secondary importance when compared to alloimmunity and immunosuppression concerns. In this review article, we focus on the epidemiological, pathophysiological and therapeutic features of non-allogeneic traditional risk factors for CKD. We also discuss the benefit of adopting a multidisciplinary approach to pursue the same therapeutic targets recommended for pre-dialysis patients.

Similar quality in chronic kidney disease multidisciplinary follow-up between kidney.

INTRODUCTION: Multidisciplinary clinics are the best approach towards Chronic Kidney Disease (CKD) patients in pre-dialysis phases. The few studies regarding kidney transplant recipients (KTR) compare multidisciplinary and non-multidisciplinary clinics. METHODS: In this study, we compared the quality of multidisciplinary CKD care between 101 KTR and 101 propensity score-matched non-transplant pre-dialysis patients (PDP). Prevalence of patients without specific treatment at any time and percent time without specific treatment for CKD complications were the main outcomes and patient and kidney function survival, glomerular filtration rate (GFR) decline, prevalence of CKD-related complications, and percent time within therapeutic goals were the exploratory ones. RESULTS: Time within most goals was similar between the groups, except for diastolic blood pressure (83.4 vs. 77.3%, RR 0.92, CI 0.88-0.97, p = 0.002) and hypertriglyceridemia (67.7 vs. 58.2%, OR 0.85, CI 0.78-0.93, p < 0.001), better in non-transplant PDP, and for proteinuria (92.7 vs. 83.5%, RR 1.1, CI 1.05-1.16, p < 0.001), better in KTR. Patient survival and GFR decline were similar between the groups, although non-transplant PDP tended to progress earlier to dialysis (9.9% vs. 6.9%, HR 0.39, p = 0.07, CI 0.14-1.08). DISCUSSION: The similar findings between non-transplant PDP and KTR suggests that good and comparable quality of multidisciplinary is a valid strategy for promoting optimal clinical management of CKD-related complications in KTR.

The prevalence and associated factors of nonadherence to antihypertensive medication in secondary healthcare.

PURPOSE: Non-adherence (NA) to medication is a major contributor to treatment failure in hypertensive patients. Factors of the ecological model, at family/healthcare professional, service, and system levels, are rarely evaluated as correlates of NA in hypertensive patients. METHODS: This crossectional study assessed the prevalence of and associated factors of NA to antihypertensive medication among 485 hypertensive patients upon receiving secondary healthcare. The Morisky Green Levine Scale (MGLS) measured the implementation phase of adherence, and the Short Assessment of Health Literacy for Portuguese-speaking Adults (SAHLPA) instrument, health literacy. Multivariate analysis to NA included variables according to the levels of the ecological model. RESULTS: Most patients were female (56.3%), white (53.2%), mean age of 62.0 ± 12.6 years, illiterate (61.6%), with low health literacy (70.9%), and low income (65.4%). Uncontrolled BP was frequent (75.2%); 57.1% of patients were nonadherent. In multivariate analysis based on the ecological model, adjusted for micro, meso- and macro-level correlates, NA was associated only with variables of patient-level: low health literacy (OR 1.62, CI 1.07-2.44, p = 0.020), income ≥ two reference wages (OR 0.46, CI 0.22-0.93, p = 0.031), lack of homeownership (OR 1.99, CI 1.13-3.51, p = 0.017), sedentarism (OR 1.78, CI 1.12-2.83, p = 0.014), and complexity of treatment (number of medications taken ≥ two times/day) (OR 1.56, CI 1.01-2.41, p = 0.042). CONCLUSION: In this group of severely hypertensive patients with high cardiovascular risk, only patient-related characteristics were associated with NA. Our findings highlight the need for effective actions to optimize clinical outcomes in similar healthcare programs.

Screening of family members of chronic kidney disease patients with Fabry disease mutations: a very important and underrated task.

INTRODUCTION: Fabry disease is a chronic, progressive, and multi-system hereditary condition, related to an Xq22 mutation in X chromosome, which results in deficiency of alpha-galactosidase enzyme, hence reduced capacity of globotriaosylceramide degradation. OBJECTIVES: to evaluate the prevalence of Fabry disease (FD) mutations, as well as its signs and symptoms, among relatives of chronic kidney disease (CKD) patients diagnosed with FD during a previously conducted study, named "Clinical and epidemiological analysis of Fabry disease in dialysis centers in Brazil". METHODS: a cross-sectional study was carried out, and data was collected by interviewing the relatives of patients enrolled in the Brazil Fabry Kidney Project and blood tests for both Gb3 dosage and genetic testing. RESULTS: Among 1214 interviewed relatives, 115 (9.47%) were diagnosed with FD, with a predominance of women (66.10%). The most prevalent comorbidities were rheumatologic conditions and systemic hypertension (1.7% each), followed by heart, neurological, cerebrovascular diseases, and depression in 0.9% of individuals. Intolerance to physical exercise and tiredness were the most observed symptoms (1.7%), followed by periodic fever, intolerance to heat or cold, diffuse pain, burn sensation or numbness in hands and feet, reduced or absent sweating, as well as abdominal pain after meals in 0.9%. CONCLUSION: We found a prevalence of Fabry disease in 9.47% of relatives of CKD patients with this condition, remarkably with a 66.1% predominance of women, which contrasts with previous reports. The screening of family members of FD patients is important, since it can lead to early diagnosis and treatment, thus allowing better quality of life and improved clinical outcomes for these individuals.

Public Knowledge and Attitudes Toward Organ Donation and Transplantation: A Survey From a Medium-Sized Brazilian City.

INTRODUCTION: In Brazil, where organ donation occurs after brain death (BD) and needs family consent, notification of potential donors increased in the last decade, although family refusal is still around 40%. Among modifiable factors, there is a lack of knowledge by the population regarding BD and the process of organ donation. Our goal was to evaluate the knowledge of the population about these topics in a medium-sized Brazilian city with a high family refusal rate. METHODS: In a cross-sectional study, we randomly recruited 868 individuals in public places in January through March 2017. We collected data about demographics and concepts related to organ donation by interview. Groups were compared by χ2 test. RESULTS: Most of the subjects were women (57.3%), 54.6% of whom were white, and the mean age was 37.1 ±15.8 years; 58.8% had at least 11 years of schooling, and 55.8% had a monthly familiar income of < 3 reference wages. Individuals who declared to be donors (67.5%) were younger (36.0 ± 14.9 vs 39.6 ± 17.4 years, P = .007) and had higher schooling (47.3 vs 28.7% with > 11 years of schooling, P < .001). Among donors, 41% did not inform their families, 38% believed that donation could occur regardless of the kind of death, and 26.8% believed in the reversibility of BD. At least 90% of individuals, however, independent from donation status, would authorize organ donation of a relative if they previously knew the donation status of that relative. CONCLUSION: We observed, despite a high prevalence of potential donors, conflictive concepts regarding BD. This information suggests directions for the design of educative measures.

Effect of cross-linked chitosan iron (III) on vascular calcification in uremic rats.

Cross-linked chitosan iron (III) is a chitin-derived polymer with a chelating effect on phosphorus, but it is untested in vascular calcification. We evaluated this compound's ability to reduce hyperphosphatemia and its effect on vascular calcification in uremic rats using an adenine-based, phosphorus-rich diet for seven weeks. We used a control group to characterize the uremia. Uremic rats were divided according the treatment into chronic kidney disease, CKD-Ch-Fe(III)CL (CKD-Ch), CKD-calcium carbonate, or CKD-sevelamer groups. We measured creatinine, phosphorus, calcium, alkaline phosphatase, phosphorus excretion fraction, parathyroid hormone, and fibroblast growth factor 23. Vascular calcification was assessed using the aortic calcium content, and a semi-quantitative analysis was performed using Von Kossa and hematoxylin-eosin staining. At week seven, rats in the chronic kidney disease group had higher creatinine, phosphorus, phosphorus excretion fraction, calcium, alkaline phosphatase, fibroblast growth factor 23, and aortic calcium content than those in the Control group. Treatments with cross-linked chitosan iron (III) and calcium carbonate prevented phosphorus increase (20%-30% reduction). The aortic calcium content was lowered by 88% and 85% in the CKD-Ch and CKD-sevelamer groups, respectively. The prevalence of vascular changes was higher in the chronic kidney disease and CKD-calcium carbonate (62.5%) groups than in the CKD-Ch group (37.5%). In conclusion, cross-linked chitosan iron (III) had a phosphorus chelating effect similar to calcium carbonate already available for clinical use, and prevented calcium accumulation in the aorta. Impact statement Vascular calcification (VC) is a common complication due to CKD-related bone and mineral disorder (BMD) and is characterized by deposition of calcium in vessels. Effective therapies are not yet available but new phosphorus chelators can prevent complications from CV. We tested the effect of chitosan, a new phosphorus chelator, on the VC of uremic animals. It has recently been proposed that chitosan treatment may be effective in the treatment of hyperphosphataemia. However, its action on vascular calcification has not been investigated yet. In this study, we demonstrated that chitosan reduced the calcium content in the aorta, suggesting that this may be a therapeutic approach in the treatment of hyperphosphatemia by preventing CV.

Severe sepsis from a Ciprofloxacin resistant salmonellosis in a kidney transplant recipient.

INTRODUCTION: Salmonellosis is a relatively rare complication in kidney transplant recipients that cannot be clinically distinguished from other forms of enteritis. Among kidney transplant patients, it varies broadly in intensity, and is highly associated with extra-intestinal disease, bacteremia, and, in this case, a high mortality rate. CASE REPORT: Here we describe a clinical case of ciprofloxacin resistant salmonellosis in a kidney transplant patient. CONCLUSION: This case illustrates how immunosuppressed patients can be exposed to rare forms of infection, often clinically difficult to identify, and possibly with severe clinical courses and poor outcomes despite evidence-based empiric antibiotic therapy.

Are Kidney Transplant Patients Receiving Chronic Kidney Disease Treatment? A Comparative Study to Predialysis Patients in a Multidisciplinary Setting.

OBJECTIVES: Kidney transplant recipients present with treatable complications related to chronic kidney disease, similarly to predialysis patients. The role of multidisciplinary clinics in the management of these complications in kidney transplant recipients is not fully understood. The objective of the present study was to compare the availability of specific treatments for chronic kidney disease-related complications between predialysis patients and kidney transplant recipients, both followed by a multidisciplinary team. MATERIALS AND METHODS: In a cross-sectional study, we compared the prevalence of chronic kidney disease-related complications and the presence or absence of treatment for those complications, when clinically indicated, in 133 kidney transplant recipients and 114 predialysis patients, all followed by a multidisciplinary team of nephrologists, nurses, dieticians, social workers, and psychologists. RESULTS: Kidney transplant recipients were younger, had better kidney function, and lower prevalence of hypertension, proteinuria, diabetes, obesity, cardiovascular disease, anemia, hyperuricemia, hypocalcemia, and hyperphosphatemia. However, the availability of treatment for anemia (odds ratio of 0.58; 95% confidence interval, 0.2-1.6; P = .31), dyslipidemia (odds ratio of 0.9; 95% confidence interval, 0.3-2.4; P = .84), metabolic acidosis (odds ratio of 3.75; 95% confidence interval, 0.8-18.2; P = .101), hyperphosphatemia (odds ratio of 1.89; 95% confidence interval, 0.3-10.8; P = .47), and hyperuricemia (odds ratio of 1.3; 95% confidence interval, 0.3-6.2; P = .73) was similar between the groups. CONCLUSIONS: Despite clinical and demographic differences, the comparable treatment directed to chronic kidney disease-related complications for both predialysis patients and kidney transplant recipients suggests that a multidisciplinary approach could be appropriate for better clinical management of chronic kidney disease in kidney transplant recipients.

Similar quality in chronic kidney disease multidisciplinary follow-up between kidney / Qualidade semelhante no acompanhamento multidisciplinar de doença renal crônica entre pacientes pré-dialíticos transplantados e não transplantados

Abstract Introduction: Multidisciplinary clinics are the best approach towards Chronic Kidney Disease (CKD) patients in pre-dialysis phases. The few studies regarding kidney transplant recipients (KTR) compare multidisciplinary and non-multidisciplinary clinics. Methods: In this study, we compared the quality of multidisciplinary CKD care between 101 KTR and 101 propensity score-matched non-transplant pre-dialysis patients (PDP). Prevalence of patients without specific treatment at any time and percent time without specific treatment for CKD complications were the main outcomes and patient and kidney function survival, glomerular filtration rate (GFR) decline, prevalence of CKD-related complications, and percent time within therapeutic goals were the exploratory ones. Results: Time within most goals was similar between the groups, except for diastolic blood pressure (83.4 vs. 77.3%, RR 0.92, CI 0.88-0.97, p = 0.002) and hypertriglyceridemia (67.7 vs. 58.2%, OR 0.85, CI 0.78-0.93, p < 0.001), better in non-transplant PDP, and for proteinuria (92.7 vs. 83.5%, RR 1.1, CI 1.05-1.16, p < 0.001), better in KTR. Patient survival and GFR decline were similar between the groups, although non-transplant PDP tended to progress earlier to dialysis (9.9% vs. 6.9%, HR 0.39, p = 0.07, CI 0.14-1.08). Discussion: The similar findings between non-transplant PDP and KTR suggests that good and comparable quality of multidisciplinary is a valid strategy for promoting optimal clinical management of CKD-related complications in KTR.

Resumo Introdução: Clínicas multidisciplinares são a melhor abordagem para pacientes com doença renal crônica (DRC) em fases pré-dialíticas. Os poucos estudos sobre receptores de transplante renal (RTR) comparam clínicas multidisciplinares e não multidisciplinares. Métodos: Neste estudo, comparamos a qualidade do atendimento multidisciplinar para DRC entre 101 RTR e 101 pacientes pré-dialíticos (PPD) não transplantados pareados com escore de propensão. A prevalência de pacientes sem tratamento específico em qualquer momento e a porcentagem de tempo sem tratamento específico para complicações de DRC foram nossos desfechos principais, e a sobrevida do paciente e da função renal, declínio da taxa de filtração glomerular (TFG), prevalência de complicações relacionadas à DRC e porcentagem de tempo dentro dos objetivos terapêuticos foram os exploratórios. Resultados: O tempo no alvo para a maioria dos objetivos foi semelhante entre os grupos, exceto para a pressão arterial diastólica (83,4 vs. 77,3%, RR 0,92, IC 0,88-0,97, p = 0,002) e hipertrigliceridemia (67. 7 vs. 58,2%, OR 0,85, IC 0,78-0,93, p < 0,001), melhor em PPD não transplantados, e para proteinúria (92,7 vs. 83,5%, RR 1,1, IC 1,05-1,16, p < 0,001), melhor em RTR. A sobrevida do paciente e o declínio da TFG foram semelhantes entre os grupos, embora PPD não transplantados tendessem a progredir mais cedo para a diálise (9,9% vs. 6,9%, HR 0,39, p = 0,07, IC 0,14-1,08). Discussão: Os resultados semelhantes entre PPD não transplantados e os RTR sugerem que a qualidade multidisciplinar boa e comparável é uma estratégia válida para promover a gestão clínica ideal de complicações relacionadas à DRC em RTR.

Low-Activity Kidney Transplant Center, A Single-Center Experience: Early Care as a Major Challenge.

OBJECTIVES: In many countries, some kidney transplants are performed in small centers, from which clinical data are rarely specifically reported. The aim of this study was to describe patient and graft survival rates and their correlates in a low-activity kidney transplant center. MATERIALS AND METHODS: We performed a retrospective cohort study of all patients who underwent transplant between January 2002 and May 2012 at a university hospital. Patient, graft, and death-censored graft survival rates were assessed with Kaplan-Meier analyses and compared by log-rank test, with associated factors analyzed by Cox proportional hazards modeling. RESULTS: Among a total of 162 patients, the mean age was 41.8 ± 13.5 years, and 92% received a living-donor graft. At 1, 3, and 5 years, patient survival was 88.6%, 86%, and 82.9%. Graft survival was 86.9%, 83%, and 77%, and death-censored graft survival was 98.1%, 96.6%, and 92.9% at the same time points. Most graft losses were due to patient death from infection and occurred within the first year after transplant. After adjustment, age over 42 years (hazard ratio of 3.94; 95% confidence interval, 1.39-11.13), deceased donor graft (hazard ratio of 11.41; 95% confidence interval, 1.2-108.35), and higher average education (hazard ratio of 4.96; 95% confidence interval, 1.01-24.32) were independently associated with graft loss. CONCLUSIONS: The observed patient and graft survival rates were similar to those described in large databases; however, early mortality remains a major challenge. Improving posttransplant care is a key issue to increasing survival in small transplant centers.

Low-Activity Kidney Transplant Center, A Single-Center Experience: Early Care as a Major Challenge.

OBJECTIVES: In many countries, some kidney transplants are performed in small centers, from which clinical data are rarely specifically reported. The aim of this study was to describe patient and graft survival rates and their correlates in a low-activity kidney transplant center. MATERIALS AND METHODS: We performed a retrospective cohort study of all patients who underwent transplant between January 2002 and May 2012 at a university hospital. Patient, graft, and death-censored graft survival rates were assessed with Kaplan-Meier analyses and compared by log-rank test, with associated factors analyzed by Cox proportional hazards modeling. RESULTS: Among a total of 162 patients, the mean age was 41.8 ± 13.5 years, and 92% received a living-donor graft. At 1, 3, and 5 years, patient survival was 88.6%, 86%, and 82.9%. Graft survival was 86.9%, 83%, and 77%, and death-censored graft survival was 98.1%, 96.6%, and 92.9% at the same time points. Most graft losses were due to patient death from infection and occurred within the first year after transplant. After adjustment, age over 42 years (hazard ratio of 3.94; 95% confidence interval, 1.39-11.13), deceased donor graft (hazard ratio of 11.41; 95% confidence interval, 1.2-108.35), and higher average education (hazard ratio of 4.96; 95% confidence interval, 1.01-24.32) were independently associated with graft loss. CONCLUSIONS: The observed patient and graft survival rates were similar to those described in large databases; however, early mortality remains a major challenge. Improving posttransplant care is a key issue to increasing survival in small transplant centers.

Screening of family members of chronic kidney disease patients with Fabry disease mutations: a very important and underrated task / Triagem de familiares de pacientes com doença renal crônica com mutação na doença de Fabry: uma tarefa muito importante e subestimada

ABSTRACT Introduction: Fabry disease is a chronic, progressive, and multi-system hereditary condition, related to an Xq22 mutation in X chromosome, which results in deficiency of alpha-galactosidase enzyme, hence reduced capacity of globotriaosylceramide degradation. Objectives: to evaluate the prevalence of Fabry disease (FD) mutations, as well as its signs and symptoms, among relatives of chronic kidney disease (CKD) patients diagnosed with FD during a previously conducted study, named "Clinical and epidemiological analysis of Fabry disease in dialysis centers in Brazil". Methods: a cross-sectional study was carried out, and data was collected by interviewing the relatives of patients enrolled in the Brazil Fabry Kidney Project and blood tests for both Gb3 dosage and genetic testing. Results: Among 1214 interviewed relatives, 115 (9.47%) were diagnosed with FD, with a predominance of women (66.10%). The most prevalent comorbidities were rheumatologic conditions and systemic hypertension (1.7% each), followed by heart, neurological, cerebrovascular diseases, and depression in 0.9% of individuals. Intolerance to physical exercise and tiredness were the most observed symptoms (1.7%), followed by periodic fever, intolerance to heat or cold, diffuse pain, burn sensation or numbness in hands and feet, reduced or absent sweating, as well as abdominal pain after meals in 0.9%. Conclusion: We found a prevalence of Fabry disease in 9.47% of relatives of CKD patients with this condition, remarkably with a 66.1% predominance of women, which contrasts with previous reports. The screening of family members of FD patients is important, since it can lead to early diagnosis and treatment, thus allowing better quality of life and improved clinical outcomes for these individuals.

RESUMO Introdução: A doença de Fabry é uma condição hereditária crônica, progressiva e multissistêmica, relacionada a uma mutação Xq22 no cromossomo X, que resulta em deficiência da enzima alfa-galactosidase, diminuindo a capacidade de degradação da globotriaosilceramida. Objetivos: avaliar a prevalência de mutações na doença de Fabry, bem como seus sinais e sintomas, em familiares de pacientes com doença renal crônica (DRC) diagnosticados com DF durante um estudo realizado anteriormente, denominado "Análise clínica e epidemiológica da doença de Fabry em centros de diálise no Brasil". Métodos: foi realizado um estudo transversal e os dados foram coletados através da entrevista com familiares de pacientes inscritos no Projeto Rim Fabry Brasil e exames de sangue para dosagem de Gb3 e testes genéticos. Resultados: Dos 1,214 familiares entrevistados, 115 (9,47%) foram diagnosticados com DF, com predomínio de mulheres (66,10%). As comorbidades mais prevalentes foram condições reumatológicas e hipertensão arterial sistêmica (1,7% cada), seguidas por doenças cardíacas, neurológicas, cerebrovasculares e depressão em 0,9% dos indivíduos. Intolerância ao exercício físico e cansaço foram os sintomas mais observados (1,7%), seguidos de febre periódica, intolerância ao calor ou ao frio, dor difusa, sensação de queimação ou dormência nas mãos e nos pés, sudorese reduzida ou ausente, além de dor abdominal após refeições em 0,9%. Conclusão: Encontramos uma prevalência da doença de Fabry em 9,47% dos familiares de pacientes com DRC com essa condição, notadamente com uma predominância de 66,1% de mulheres, o que contrasta com relatos anteriores. A triagem de familiares de pacientes com DF é importante, pois pode levar ao diagnóstico e tratamento precoces, permitindo melhor qualidade de vida e melhores resultados clínicos para esses indivíduos.

Severe sepsis from a Ciprofloxacin resistant salmonellosis in a kidney transplant recipient / Sepse grave por salmonelose Ciprofloxacino-resistente em paciente transplantado renal

Abstract Introduction: Salmonellosis is a relatively rare complication in kidney transplant recipients that cannot be clinically distinguished from other forms of enteritis. Among kidney transplant patients, it varies broadly in intensity, and is highly associated with extra-intestinal disease, bacteremia, and, in this case, a high mortality rate. Case Report: Here we describe a clinical case of ciprofloxacin resistant salmonellosis in a kidney transplant patient. Conclusion: This case illustrates how immunosuppressed patients can be exposed to rare forms of infection, often clinically difficult to identify, and possibly with severe clinical courses and poor outcomes despite evidence-based empiric antibiotic therapy.

Resumo Introdução: A salmonelose é uma complicação relativamente rara em transplantados renais, e não pode ser diferenciada de outras formas de enterite pela apresentação clínica. Em pacientes transplantados renais, a salmonelose varia em gravidade, e é frequentemente associada com formas extra intestinais, bacteremia, e, neste caso, com elevada mortalidade. Relato de Caso: Descrevemos o caso clínico de um paciente transplantado renal com salmonelose Ciprofloxacino-resistente. Conclusão: Este caso ilustra o risco, relacionado à imunossupressão, da ocorrência de formas raras de infecção, por vezes de difícil diagnóstico, e com cursos clínicos potencialmente graves e prognóstico ruim, apesar do emprego de antibioticoterapia empírica adequada e de acordo com as evidências disponíveis.

Salmonella peritonitis in a patient on automated peritoneal dialysis.

We describe the clinical course of a case of peritonitis caused by Salmonella sp. after an episode of intestinal salmonellosis, and a brief review of the literature is also done.

[Posttransplant chronic anemia: parvovirus B19]. / Anemia crônica no pós-transplante renal: parvovirose B19.

Anemia is frequent in kidney transplant patients, and its prevalence varies according to posttransplant time and the adopted diagnostic criteria. Parvovirus B19 (PV B19) infection is an underdiagnosed cause of anemia in this particular population. To illustrate epidemiologic and clinical data regarding it, we present a case of PV B19 infection complicated by pure red cell aplasia (PRCA), pointing out the pitfalls we encountered in diagnosis and treatment. The use of viral DNA detection by polymerase chain reaction (PCR), and correct interpretation of morphological features of bone marrow histology are particularly important for the diagnosis of this condition in kidney transplant patients, who fail to develop a proper humoral response against PV B19, thus importantly decreasing the sensitivity of serological methods in this setting.

Association between laboratory and clinical risk factors and progression of the predialytic chronic kidney disease.

INTRODUCTION: Chronic kidney disease (CKD) is a very common condition that has become a public health issue. Knowing more about risk factors associated with the progression of CKD allows therapeutic interventions that may change the natural course of the disease. OBJECTIVE: To evaluate the impact of clinical and laboratory variables at admission on the outcomes death and need for renal replacement therapy (RRT). METHODS: A retrospective cohort study comprised of 211 adult patients with stages 3-5 CKD, followed-up for 56.6 ± 34.5 months. RESULTS: Mean age of patients was 65.4 ± 15.1 years and 63.5% were > 60 years. The main causes of CKD were hypertensive nephrosclerosis (29%) and diabetic kidney disease (DKD) (17%). Most patients (47.3%) were on stage 4 CKD. The mean annual loss of glomerular filtration rate (GFR) was 0.6 ± 2.5 mL/min/1.73 m² (median 0.77 mL/min/1.73 m²) After the adjustments for demographic, clinical and laboratory variables, DKD [relative risk (RR) 4.4; 95% confidence interval (CI), 1.47 to 13.2; p = 0.008] was predictive of RRT; age (RR 1.09; 95% CI, 1.04 to 1.15; p < 0.0001) and the non-treatment with angiotensin receptor blocker (ARB) (RR 4.18, 95% CI, 1.34 to 12.9; p = 0.01) were predictors of death. Renal and patient survival rates were 70.9% and 68.6%, respectively. CONCLUSION: In this study, patients with stage 3-5 CKD treated conservatively showed stabilization of renal function and low mortality, which were impacted by DKD, age and to not using ARB, respectively.

Anemia crônica no pós-transplante renal: parvovirose B19 / Posttransplant chronic anemia: parvovirus B19

A anemia é frequente em pacientes após o transplante renal (TxR) e sua prevalência varia conforme o tempo pós-transplante e os critérios diagnósticos empregados. A infecção pelo Parvovírus B19 (PV B19) é causa subdiagnosticada de anemia nesta população. Para ilustrar a epidemiologia e espectro clínico, apresentamos caso de PV B19 que evoluiu com aplasia pura de série vermelha (APSV), ressaltando as dificuldades do diagnóstico e tratamento. O emprego da detecção do DNA viral pela reação em cadeia da polimerase e do diagnóstico das alterações da morfologia da medula óssea são particularmente úteis para o diagnóstico no paciente transplantado imunossuprimido que falha na produção da resposta humoral contra o PV B19.

Anemia is frequent in kidney transplant patients, and its prevalence varies according to posttransplant time and the adopted diagnostic criteria. Parvovirus B19 (PV B19) infection is an underdiagnosed cause of anemia in this particular population. To illustrate epidemiologic and clinical data regarding it, we present a case of PV B19 infection complicated by pure red cell aplasia (PRCA), pointing out the pitfalls we encountered in diagnosis and treatment. The use of viral DNA detection by polymerase chain reaction (PCR), and correct interpretation of morphological features of bone marrow histology are particularly important for the diagnosis of this condition in kidney transplant patients, who fail to develop a proper humoral response against PV B19, thus importantly decreasing the sensitivity of serological methods in this setting.

Associação entre fatores de risco clínicos e laboratoriais e progressão da doença renal crônica pré-dialítica / Association between laboratory and clinical risk factors and progression of the predialytic chronic kidney disease

INTRODUÇÃO: A doença renal crônica (DRC) é muito prevalente e representa um importante problema de saúde pública. O maior conhecimento dos fatores de risco relacionados à progressão da DRC permite adotar estratégias terapêuticas que podem alterar o curso natural da doença. OBJETIVO: Avaliar o impacto de variáveis clínicas e laboratoriais à admissão nos desfechos de óbito e início de terapia renal substitutiva (TRS). MÉTODOS: Estudo de coorte retrospectiva, composta de 211 pacientes adultos com DRC nos estágios 3-5 tratados, acompanhados por 56,6 ± 34,5 meses. RESULTADOS: A idade média dos pacientes foi de 65,4 ± 15,1 anos, sendo 63,5% com > 60 anos. As principais etiologias de DRC foram nefroesclerose hipertensiva (29%) e doença renal diabética (DRD) (17%). A maioria dos pacientes encontrava-se no estágio 4 da DRC (47,3%). A perda média anual de taxa de filtração glomerular (TFG) foi 0,6 ± 2,5 mL/min/1,73 m² (mediana 0,7 mL/min/1,73 m²). Após os ajustes para as variáveis demográficas, clínicas e laboratoriais, concluiu-se que apresentar DRD [risco relativo (RR) 4,4; intervalo de confiança (IC) 95%, 1,47-13,2; p = 0,008] foi preditor de TRS e a idade (RR 1,09; IC 95%, 1,04-1,15; p < 0,0001) e o não tratamento com bloqueador do receptor da angiotensina (BRA) (RR 4,18; IC 95%, 1,34-12,9; p = 0,01) foram preditores de óbito. A sobrevida renal e a geral dos pacientes foram de 70,9% e 68,6%, respectivamente. CONCLUSÃO: Neste estudo, os pacientes com DRC nos estágios 3-5 tratados conservadoramente apresentaram estabilização funcional e baixa mortalidade, desfechos associados à DRD, idade e não tratamento com BRA.

INTRODUCTION: Chronic kidney disease (CKD) is a very common condition that has become a public health issue. Knowing more about risk factors associated with the progression of CKD allows therapeutic interventions that may change the natural course of the disease. OBJECTIVE: To evaluate the impact of clinical and laboratory variables at admission on the outcomes death and need for renal replacement therapy (RRT). METHODS: A retrospective cohort study comprised of 211 adult patients with stages 3-5 CKD, followed-up for 56.6 ± 34.5 months. RESULTS: Mean age of patients was 65.4 ± 15.1 years and 63.5% were > 60 years. The main causes of CKD were hypertensive nephrosclerosis (29%) and diabetic kidney disease (DKD) (17%). Most patients (47.3%) were on stage 4 CKD. The mean annual loss of glomerular filtration rate (GFR) was 0.6 ± 2.5 mL/min/1.73 m² (median 0.77 mL/min/1.73 m²) After the adjustments for demographic, clinical and laboratory variables, DKD [relative risk (RR) 4.4; 95% confidence interval (CI), 1.47 to 13.2; p = 0.008] was predictive of RRT; age (RR 1.09; 95% CI, 1.04 to 1.15; p < 0.0001) and the non-treatment with angiotensin receptor blocker (ARB) (RR 4.18, 95% CI, 1.34 to 12.9; p = 0.01) were predictors of death. Renal and patient survival rates were 70.9% and 68.6%, respectively. CONCLUSION: In this study, patients with stage 3-5 CKD treated conservatively showed stabilization of renal function and low mortality, which were impacted by DKD, age and to not using ARB, respectively.

Insuficiência renal aguda nefrotóxica: prevalência, evolução clínica e desfecho / Nephrotoxic acute renal failure: prevalence, clinical course and outcome

Introdução: A insuficiência renal aguda (IRA) nefrotóxica é frequente e importante causa de morbimortalidade. objetivo: Avaliar a prevalência, o curso clínico e o desfecho da IRA nefrotóxica. pacientes e Métodos: Coorte histórica realizada em um hospital de ensino terciário, no período de fevereiro a novembro de 1997. Foram incluídos pacientes acima de 12 anos, com diagnóstico de IRA, acompanhados pela equipe de Interconsulta de Nefrologia. Foram excluídos transplantados renais, portadores de insuficiência renal crônica, dialisados por intoxicação exógena e aqueles transferidos de hospital durante o tratamento. Resultados: Dos 234 pacientes acompanhados, 12% apresentaram IRA nefrotóxica e 24%, IRA multifatorial associada ao uso de drogas nefrotóxicas. Entre as comorbidades mais prevalentes, estão hipertensão arterial, hepatopatias, neoplasias, insuficiência cardíaca congestiva e diabetes mellitus. Quinze por cento necessitaram de diálise, e o tipo mais frequentemente usado foi hemodiálise venovenosa contínua; 42% eram oligúricos, 44,7% evoluíram para óbito e 33% recuperaram a função renal. Antibióticos, AINH e contraste radiológico foram as drogas nefrotóxicas mais prevalentes. Os medicamentos nefrotóxicos implicados foram, em ordem de frequência, vancomicina, aminoglicosídeos, aciclovir, quimioterápicos e contraste radiológico. Hepatopatia foi a única variável com significância estatística (p=0,03, IC= 1,08 a 6,49) em análise multivariada. Na comparação entre IRA nefrotóxica, houve aumento da mortalidade proporcionalmente aos dias de internação. Conclusão: IRA nefrotóxica é frequente, grave e deve ser continuamente monitorada, tanto ambulatorialmente quanto no ambiente intra-hospitalar.

Background: Acute renal failure (ARF) is frequent and important cause of morbidity and mortality. Objective: To evaluate the prevalence, clinical course and outcome of nephrotoxic ARF. Patients and Methods: This historical cohort study conducted in a tertiary hospital in the period from February to November 1997. We included patients over 12 years, diagnosed with ARF, accompanied by a team of nephrologists. Were excluded from renal transplant patients, patients with chronic renal failure, dialysis with exogenous poisoning and those transferred to hospital during treatment. Results: Of 234 patients enrolled, 12% had nephrotoxic ARF, and 24% multifactorial ARF associated with the use of nephrotoxic drugs. Among the most prevalent comorbidities are arterial hypertension, liver diseases, cancer, congestive heart failure and diabetes mellitus. Fifteen percent required dialysis, and the type most often used was continuous venovenous hemodialysis, 42% were oliguric, 44.7% died and 33% recovered renal function. Antibiotics, NSAIDs and contrast radiological nephrotoxic drugs were more prevalent. The nephrotoxic drugs were, in order of frequency, vancomycin, aminoglycosides, acyclovir, chemotherapy and radiological contrast. Liver was the only variable with statistical significance (p = 0.03, CI = 1.08 to 6.49) in multivariate analysis. In comparison nephrotoxic ARF, there was increased mortality proportional to the length of hospitalization. Conclusion: Nephrotoxic ARF is common, serious and must be continuously monitored, both outpatient and in-hospital setting.