Scielo RSS http://scielo.pt/rss.php?pid=0872-016920200002&lang=pt vol. 34 num. 2 lang. pt http://scielo.pt/img/en/fbpelogp.gif http://scielo.pt http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692020000200001&lng=pt&nrm=iso&tlng=pt Returning to dialysis after kidney transplant loss is one of the most difficult transitions for chronic kidney disease patients and their assistant nephrologists. These patients have an increased mortality rate on dialysis and re-transplantation is often difficult due to human leukocyte antigen sensitization narrowing possible donors. The decision on the right timing to start dialysis, vascular access management, optimal immunosuppression withdrawal, graft nephrectomy impact and re-transplant planning are just some of the issues that need to be addressed. However, the optimal care for kidney transplant patients with a failing renal graft is still undefined. In this article we will address this challenging new chapter that affects a growing number of chronic kidney disease patients, with a special focus on allosensitization and immunosuppression withdrawal. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692020000200002&lng=pt&nrm=iso&tlng=pt Returning to dialysis after kidney transplant loss is one of the most difficult transitions for chronic kidney disease patients and their assistant nephrologists. These patients have an increased mortality rate on dialysis and re-transplantation is often difficult due to human leukocyte antigen sensitization narrowing possible donors. The decision on the right timing to start dialysis, vascular access management, optimal immunosuppression withdrawal, graft nephrectomy impact and re-transplant planning are just some of the issues that need to be addressed. However, the optimal care for kidney transplant patients with a failing renal graft is still undefined. In this article we will address this challenging new chapter that affects a growing number of chronic kidney disease patients, with a special focus on allosensitization and immunosuppression withdrawal. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692020000200003&lng=pt&nrm=iso&tlng=pt Background: Anemia is a common complication of Chronic Kidney Disease (CKD), in which iron deficiency's (ID) role is frequently underrated. In CKD, anemia has been associated with higher morbidity and lower quality of life. Nonetheless, reported treatment rates of anemia in CKD are low and guidelines' variability and/or absence for its management and treatment may be preventing patients from receiving optimal treatment. Within this context, we aimed to assess the agreement level on anemia and iron deficiency diagnosis, management, and treatment in CKD patients, by Portuguese physicians in Nephrology, through a Delphi Panel. Methods: A group of seven medical experts in Nephrology and Transfusion Medicine was assembled, and a focus group was conducted, in which 28 statements were agreed upon. Then, a two-round Delphi Panel using a Likert scale was conducted online, inviting Portuguese Society of Nephrology associates to participate. Results: Answers were collected from 76 participants in Round 1 and consensus level was obtained for 1 statement, 57 (75%) respondents fully disagreeing on transfusing all patients with hemoglobin below 9 g/dl, regardless of the clinical situation. The remaining 27 statements were used in Round 2, none obtaining consensus level and 14 statements being categorized as qualified majority: 4 on diagnosis, 3 on disease management, and 7 on treatment. Discussion: Our study showed a lack of consensus on diagnosis, management, and treatment of anemia in CKD patients among the nephrology community in Portugal. Overall, our results illustrated the heterogeneity of national clinical practices in: laboratory parameters' choice; cutoff values defining anemia and/or ID; parameter-based therapeutic decisions. Nonetheless, it was shown clear that patient's individual characteristics, clinical settings, and the physician's "clinical sense" seem to be considered to a further extent than the available guidelines. Future studies should be considered to develop recommendations that can be widely accepted. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692020000200004&lng=pt&nrm=iso&tlng=pt Background: Membranous nephropathy (MN) is among the most common causes of nephrotic syndrome in nondiabetic adults. The podocytic M-type phospholipase A2 receptor (PLA2R) has been identified as the major antigenic target of the immune response that underlies primary membranous nephropathy (PMN). In the last decade, anti-PLA2R antibodies have been seen as promising diagnostic biomarkers for PMN. Other potential uses include assessment of disease activity and prognosis, therapeutic monitoring and prediction of disease recurrence after renal transplant. Objective: To review clinical studies exploring the current role of anti-PLA2R antibodies. Methods: This systematic review was conducted according to PRISMA guidelines. Two databases were searched for articles published between January 2010 and August 2019. Fifty-one studies met the inclusion criteria. Results: Anti-PLA2R antibodies constitute highly sensitive and specific markers for PMN. Antibody titers correlate positively with disease activity. Low levels or seronegativity correlate to higher remission rates. Relative reduction of antibody titers seems to correlate with the likelihood of response to therapy. The value of this antibody in the prediction of post-transplant recurrence is uncertain, as is its use in the pediatric population. Conclusion: Anti-PLA2R antibodies are assuming an increasingly important role in MN management. Anti-PLA2R positivity in the context of nephrotic syndrome is very suggestive of PMN diagnosis. Nevertheless, further efforts are required to define optimal cut-off values for seropositivity and risk stratification. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692020000200005&lng=pt&nrm=iso&tlng=pt Over the past century, important scientific advances have been made regarding the complex pathophysiology of bone disease in renal patients. Bone disease in renal patients is included in a wider spectrum of disease, the CKD-mineral bone disorders (CKD-MBD). Older patients with CKD can present with both age-related osteoporosis and renal osteodystrophy. Clinicians are now challenged with the need to prevent fracture in these CKD patients, where the efficacy and safety of pharmacologic agents used for the general osteoporotic population have not been studied. Treatment of renal osteodystrophy has been focused on control of the parathyroid secretion with calcitriol, vitamin D analogs and calcimimetic agents. However, there is an increase in fractures with aging in patients with CKD, suggesting that these patients also have the fracture risk factors common to the general population, such as age. Pharmacologic agents, such as teriparatide, denosumab and romosozumab have been developed for osteoporosis treatment with a direct effect on bone cell activity, osteoblasts and osteoclasts. This article reviews the derangements in bone turnover, mineralization and volume in CKD-MBD. In addition, we will also discuss strategies to manage osteoporosis in CKD and the available data on the new pharmacological agents in CKD-patients. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692020000200006&lng=pt&nrm=iso&tlng=pt Chronic kidney disease (CKD) is a burdensome disease that has been successfully managed with dialysis. But even if dialysis can prolong patients' survival in certain circumstances, it also brings a high burden of physical and psychosocial symptoms, poor outcomes, and high costs of care. Fragile patients may not benefit from starting dialysis. In this way, Palliative Care (PC) should be integrated into CKD care to control symptoms' burden, to discuss the shared decision to start or forgo dialysis when stage 5 CKD approaches, or to select conservative management of end-stage renal disease (ESRD) or withdrawal dialysis. As patients attended in private hemodialysis units get older and more fragile, incorporation of PC is associated with the highest quality care standards provided to our ESRD patients. That being so, we designed a project based on the World Health Organization (WHO) recommendations to implement palliative interventions in NephroCare Hemodialysis Units. In our project, we consider the following five steps: (i) assessment of palliative needs in dialysis patients; (ii) team education; (iii) contact and referral to specialized teams; (iv) registration (v) and trial of the pilot project. We also reflect on the barriers to implementation of this project. This article aims to raise awareness of the project and use it as a model or a first step to other projects in the actual area to be implemented in other health units. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692020000200007&lng=pt&nrm=iso&tlng=pt Membranous nephropathy is the most common cause of nephrotic syndrome in white adults. A non-negligible number of cases are associated with systemic conditions, namely cancer. We report the case of a 70-year-old man who presented with nephrotic syndrome and was diagnosed with membranous nephropathy. Although the initial screening did not detect any neoplastic lesion, additional exams revealed a nasopharyngeal carcinoma and a complete remission of the glomerular disease was observed after treating the cancer. Considering this very rare clinical association, we discuss the pitfalls underlying cancer screening in membranous nephropathy. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692020000200008&lng=pt&nrm=iso&tlng=pt Background: Many patients with end-stage renal disease start renal replacement therapy in an unplanned manner. The vast majority initiate hemodialysis by a central venous catheter, since its use is more widespread and available. This technique is associated with a high risk of infection and damage of the vascular patrimony associated with the use of central veins. Urgent-start peritoneal dialysis comes as an alternative treatment for selected patients. Case report: A 55-year-old woman with focal segmental glomerulosclerosis presented with a rapid decline of renal function and was given renal replacement therapy counselling and opted for peritoneal dialysis. Her chosen modality was postponed for one month due to early uremic symptoms, followed by hemodialysis start through a central venous catheter. During this period a sepsis due to central venous catheter infection occurred, implying four weeks of intravenous antibiotics. Discussion and Conclusion: Although there has been an increase in the number of publications on urgent-start peritoneal dialysis, showing that this technique has comparable results either to urgent-start hemodialysis and planned-start peritoneal dialysis, there still is some resistance to the use of this modality. Given the importance of this subject, this review aims to describe and summarize the available evidence on urgent-start peritoneal dialysis outcomes. Moreover, specific barriers are addressed. Its use is encouraged in hospitals where peritoneal dialysis is available, as an opportunity to improve chronic kidney disease patient management and transition to dialysis. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692020000200009&lng=pt&nrm=iso&tlng=pt Typhlitis is a clinical entity rare in adults, reported in immunosuppressed patients. It is a life-threatening condition that occurs in neutropenic patients due to compromised integrity of the bowel wall and its exact pathogenesis is not completely understood. We report a 35-year-old man with a post deceased donor renal and pancreas transplantation status who presented fever and febrile neutropenia. Three days after admission he presented hematochezia with a hemoglobin drop. Colonoscopy revealed "ileum mucosa with multiforme ulcers" and since no other etiology was found, typhlitis was considered. He gradually improved with support treatment and was able to be managed non-operatively. To our knowledge, there are only six other reports of typhlitis in kidney transplant recipients. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692020000200010&lng=pt&nrm=iso&tlng=pt Atheroembolic renal disease is a multisystem clinical entity of unknown incidence. It is often associated with severe atherosclerotic disease and its etiology can be spontaneous or iatrogenic. Its pathophysiology is based on renal dysfunction secondary to embolization of cholesterol crystals, followed by occlusive phenomena affecting the renal vasculature. The present report describes the case of a patient with several cardiovascular risk factors, with a recent introduction of rivaroxaban. The clinical course presented was suggestive of renal atheroembolic disease, and the histological evaluation corroborated this diagnosis. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692020000200011&lng=pt&nrm=iso&tlng=pt Atheroembolic renal disease is a multisystem clinical entity of unknown incidence. It is often associated with severe atherosclerotic disease and its etiology can be spontaneous or iatrogenic. Its pathophysiology is based on renal dysfunction secondary to embolization of cholesterol crystals, followed by occlusive phenomena affecting the renal vasculature. The present report describes the case of a patient with several cardiovascular risk factors, with a recent introduction of rivaroxaban. The clinical course presented was suggestive of renal atheroembolic disease, and the histological evaluation corroborated this diagnosis. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692020000200012&lng=pt&nrm=iso&tlng=pt Atheroembolic renal disease is a multisystem clinical entity of unknown incidence. It is often associated with severe atherosclerotic disease and its etiology can be spontaneous or iatrogenic. Its pathophysiology is based on renal dysfunction secondary to embolization of cholesterol crystals, followed by occlusive phenomena affecting the renal vasculature. The present report describes the case of a patient with several cardiovascular risk factors, with a recent introduction of rivaroxaban. The clinical course presented was suggestive of renal atheroembolic disease, and the histological evaluation corroborated this diagnosis. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692020000200013&lng=pt&nrm=iso&tlng=pt Atheroembolic renal disease is a multisystem clinical entity of unknown incidence. It is often associated with severe atherosclerotic disease and its etiology can be spontaneous or iatrogenic. Its pathophysiology is based on renal dysfunction secondary to embolization of cholesterol crystals, followed by occlusive phenomena affecting the renal vasculature. The present report describes the case of a patient with several cardiovascular risk factors, with a recent introduction of rivaroxaban. The clinical course presented was suggestive of renal atheroembolic disease, and the histological evaluation corroborated this diagnosis.