Scielo RSS http://scielo.pt/rss.php?pid=0872-016920220004&lang=pt vol. 36 num. 4 lang. pt http://scielo.pt/img/en/fbpelogp.gif http://scielo.pt http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692022000400199&lng=pt&nrm=iso&tlng=pt http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692022000400201&lng=pt&nrm=iso&tlng=pt ABSTRACT Health data science aims to extract knowledge from data allowing better decision-making, using multidisciplinary approaches from fields such as computation, statistics, epidemiology, and several medical knowledge domains. We live in the ‘big data’ era, with a growing availability of health data, in volume, variety, and velocity, also for tasks such as kidney transplantation. Hereby, secondary use of this health data must be encouraged to improve patient care planning, disease research, and policymaking around transplantation. This article presents the Transplant Open Registry (TxOR) website where some health data science applications on kidney transplantation are available. With it, we try to answer, some of the remaining questions on kidney transplantation in Portugal, with a new approach. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692022000400207&lng=pt&nrm=iso&tlng=pt ABSTRACT Introduction: There is a growing need to train nonpalliative physicians in palliative care, as it is increasingly recognized by the medical profession. Political and opinion leaders are also becoming aware of the urgent and growing need for palliative care education. Objective: The aim of this study is to provide an overview of the information available in the literature on the topic of palliative care competencies for nephrologists, using clearly defined and transparent methods to search, summarize, and interpret the relevant literature based on a systematic review approach. Methods: The scoping review is based on the Joanna Briggs Institute methodology. The search was conducted in December 2019 using publications in national and international databases and grey literature in English, Spanish, French and Portuguese. Results: Of the total 4668 publications, 168 were eligible for review based on title and abstract. A full-text review of these 168 publications resulted in the selection of 27 articles that met the predefined inclusion and exclusion criteria and were therefore included in the study. The following competencies were considered necessary to provide high quality PC in various nephrology settings: Communication skills (21.3%); End-of-life care, loss, grief, and bereavement (18.6%); Control of pain and other renal symptoms (16%); Advance care planning (16%); Ethical and legal issues in dialysis decision making (12.2%); Teamwork (6.6%); Ability to provide psychosocial and spiritual support to patients and families (5.6%). Application of palliative care principles (3.7%). Percentage refers to the number of publications addressing each topic. Conclusion: The implementation of an integrated care model that includes both PC and curative treatments places high demands on nephrologists, who must acquire PC competencies. Training in palliative care should be included in the curricula for nephrologists. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692022000400215&lng=pt&nrm=iso&tlng=pt ABSTRACT Introduction: Acute kidney injury (AKI) is a major complication in critically ill septic patients and is associated with increased morbidity and mortality. A recent study suggested a risk score based on patient’s chronic comorbidities and acute events at intensive care unit (ICU) admission as a reliable tool for predicting AKI in critically ill adult population. The aim of this study was to adapt this score to septic-AKI patients and evaluate its prognostic value as predictor of the need for renal replacement therapy (RRT) at ICU admission. Methods: This is a retrospective analysis of 399 septic-AKI patients admitted to the Division of Intensive Medicine of the Centro Hospitalar Universitário Lisboa Norte between January 2008 and December 2014. The Kidney Disease Improving Global Outcomes (KDIGO) classification was used to define AKI. The Renal Replacement Therapy Risk Score was adapted from the AKI risk prediction score proposed by Malhotra et al (Nephrol Dial Transplant. 2017;32:814-22). Results: Fifty two percent of patients were KDIGO stage 3, 25.8% KDIGO stage 2 and 22.3% KDIGO stage 1. Twenty seven percent of patients required RRT. Patients requiring RRT had higher risk score than those who did not (6.6±2.5 vs 5.1 ±2.6, p<0.001). An optimal cut-off value of ≥ 6 in this score predicted the need for RRT with sensitivity 0.630 and specificity 0.391. Conclusion: The RRT risk score at ICU admission was independently associated with the requirement of RRT septic-AKI patients. The assessment of this ratio is simple and can prove useful in identifying patients at risk for need of RRT. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692022000400223&lng=pt&nrm=iso&tlng=pt ABSTRACT Introduction: ANCA associated vasculitis commonly affects the kidneys. The intense inflammatory damage disrupts the glomerular architecture. Induction immunosuppressive therapy is responsible for a large part of the morbidity and mortality of these patients, due to infectious complications. This highlights the importance of defining risk factors associated with a worse renal prognosis in order to select the patients who would benefit the most from immunosuppressive therapy when it comes to renal limited vasculitis. Methods: Retrospective collection of data from patients admitted to the Coimbra’s University Hospital Nephrology Department with the diagnosis of de novo ANCA vasculitis, between 01-06-2009 and 01-06-2019. Data were analysed with SPSS v26® using parametric and nonparametric tests, Kaplan Meyer survival and ROC curve analysis. Results: There were 81 cases of de novo vasculitis, mainly due to anti-MPO antibody associated vasculitis (N=69; 85.2%). Mean age at diagnosis was 67.4 ± 15.7 years and most patients were male (N=47; 58%). At admission, patients had a mean serum creatinine (sCr) of 6.8 ± 4.0 mg/dL. Dialysis was required in 23 (28.4%) patients at admission and 44.4% were dependent on renal replacement therapy at discharge. Among dialysis-dependent patients at discharge treated with immunosuppression for at least 3 months (N=15) we observed partial kidney recovery in 2 (13.3%). Deaths were mostly (N=8/11; 72.7%) caused by infections. Discussion: Our results call into question the need for aggressive induction treatment in dialysis-dependent patients without extrarenal manifestations. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692022000400233&lng=pt&nrm=iso&tlng=pt ABSTRACT Pneumocystis jirovecii (PJ) opportunistic infections occur in immunocompromised patients impacting significantly hospitalizations and mortality. Trimethoprim-sulfamethoxazole (TMP-SMX) is universally used as prophylaxis of Pneumocystis jirovecii pneumonia (PJP) and therefore, this infection is rare condition in solid organ transplant (SOT) recipients. We present a case of a 46-years-old male, who received an ABO-incompatible transplant with prior desensitization protocol with plasmapheresis, rituximab, and anti-CMV immunoglobulin. IgG anti-B title pre-desensitization was 1:128. The patient had 6 ABDR mismatches, without HLA antibodies, and the CDC crossmatch for T and B cells was negative. Both recipient and donor were CMV positive (D+/R+). The patient received induction immunosuppression with corticosteroids, basiliximab, calcineurin inhibitor, and mycophenolate mofetil. Immediate kidney function was verified, and three additional plasmapheresis sessions were performed. At discharge serum creatinine (sCr) was 1.38 mg/dL, but kidney function declined during the first 6 months (sCr 2.5 mg/dL). Urinalysis was unremarkable. A kidney biopsy was declined by the patient. Unit protocol maintained the prophylaxis for PJP and cytomegalovirus (CMV) infection with TMP-SMX and valganciclovir. The patient was admitted to the emergency department 20 months after the transplant with respiratory symptoms and was diagnosed with PJP. Bronchoalveolar lavage fluid was also positive for CMV. Intensive care unit (ICU) admission was necessary due to clinical deterioration, with subsequent good evolution without mechanical ventilation. At discharge, prophylaxis with TMP-SMX and valganciclovir was maintained for more than six months. Here we discuss the late onset of PJP, and the main risk factors related to severe infection. Transplant subgroups in which longer PJP prophylaxis could be beneficial and the indication to re-start PJP prophylaxis is still under discussion. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692022000400237&lng=pt&nrm=iso&tlng=pt ABSTRACT Reports of spontaneous remissions in minimal change disease are rare and often associated with secondary causes. We report the case of a 47-year-old male patient with HIV-HBV/HDV co-infection and cirrhosis, admitted in the emergency department with nephrotic syndrome (hypoalbuminemia 1.2 g/dL and nephrotic range proteinuria 14 440 mg/g of creatinine). Ultrasound showed normal kidneys. Viral load for HIV, HBV, HDV and anti-HCV were negative. Immunologic and dysproteinemia study was normal and there were no signs of malignancy on body computer tomography scan. Abdominal fat pad biopsy was Congo red-stain negative. After initiating an angiotensin-converting enzyme inhibitor, the proteinuria decreased to 3891 mg/g. A kidney biopsy was scheduled, but the patient abandoned follow-up. Two years later, he presented again in anasarca, with mild elevation of transaminases, severe hypoalbuminemia (0.7 g/dL), acute kidney injury (creatinine 2.7 mg/dL) and heavy proteinuria (37 g/24 h). One month after the onset, when referred to a nephrologist, he was in complete remission. A year later, he presented a third episode of abrupt onset nephrotic syndrome. Kidney biopsy revealed minimal change disease. Corticosteroid therapy was withheld, and after one month the patient was again in complete remission. We hypothesize that, in the context of cirrhosis, the clearance of a putative permeability circulating factor may be diminished; hemodynamic changes in renal perfusion in decompensated chronic liver disease may interfere in the glomerular barrier function; and a genetic polymorphism related to podocyte dysfunction could precipitate a nephrotic syndrome that resolves once the liver function resumes its steady state. This case represents an unprecedented report of a minimal change disease in a cirrhotic patient, presenting with recurring episodes of nephrotic syndrome followed by early spontaneous remission. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692022000400241&lng=pt&nrm=iso&tlng=pt ABSTRACT Supportive care in patients with chronic kidney disease refers to the application of palliative medicine principles and practices in nephrology. The main purpose is to reduce suffering by managing symptoms, helping with decision making and providing holistic support to the patient and family/caregiver in clinical, social, spiritual or nutritional distress, with a multidisciplinary team. We present the case of a 92-year-old male patient with chronic kidney disease of unknown etiology since 2004. In 2019, he was referred to our kidney disease supportive care program, presenting a serum creatinine of 5.44 mg/dL (estimated glomerular filtration rate of 9 mL/min/1.73 m2). During the following three years, the patient lived at home independently, maintained good control of his chronic kidney diseaseassociated symptoms and preserved his functional status. We present this case as a practical example of how to approach an autonomous elderly, chronic kidney disease patient, with few comorbidities, who opted for supportive care. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692022000400246&lng=pt&nrm=iso&tlng=pt ABSTRACT Urinary tract infection is an important cause of hospitalization, morbidity and mortality, being responsible for an important fraction of health expenses. The main risk factors are urine flow obstruction, urinary catheters, immunosuppression and diabetes mellitus. We present a case of pyelonephritis that culminated in nephrectomy, finally unravelling an unexpected diagnosis. A 52-year-old male presented in the emergency department with two weeks of pain in the left iliac fossa that irradiated to the lumbar region and cloudy urine. Lab work revealed severe anaemia (4.9 g/dL), inflammatory markers elevation, leucoerythrocyturia, serum creatinine of 4.33 mg/dL and metabolic acidosis. Computed tomography scan showed a swollen left kidney with a staghorn calculus and intraparenchymal hypodensities. After a failed trial of large spectrum antibiotics, he was submitted to left radical nephrectomy with significant clinical improvement. Gross examination showed a markedly dilated pyelocalicial tree, filled with several staghorn calculi and purulent secretions with associated parenchymal atrophy. Histopathologic evaluation revealed exuberant chronic pyelonephritis with an acute inflammatory infiltrate that extended into the perinephric fat and multiple Schistosoma ova, predominantly calcified. The authors describe the case of a severe pyelonephritis with exuberant clinical and imagiological features and rare microbiological findings, suggesting previous genitourinary Schistosomiasis that predisposed to nephrolithiasis and chronic pyelonephritis. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692022000400250&lng=pt&nrm=iso&tlng=pt ABSTRACT Currently, patients older than 75 years are the fastest-growing group starting dialysis worldwide. However, the benefits of dialysis become doubtful among frail older patients and conservative kidney management (CKM) has emerged as a feasible therapeutic strategy for some patients, with a focus on quality of life and comfort. Even though it is a challenge to recognize which is the most suitable therapeutic option for elderly patients. We report a case of an 81-year-old woman who initially chose CKM, but later accepted to start hemodialysis due to difficult control of hypervolemia. During the period on dialysis, she had several complications, the most serious related to lower limb amputation, as a result of severe chronic ischemia. This case reflects the complexity of managing an older stage 5 chronic kidney disease patient, both on dialysis or CKM. Treatment decisions are complex and prognosis estimation is challenging. Time is essential to understand the benefits and burdens of different treatment strategies for each patient and the priority should be centered on optimizing care for older adults with advanced kidney disease. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692022000400254&lng=pt&nrm=iso&tlng=pt ABSTRACT For patients with end stage renal disease, kidney transplant offers significant survival and quality-of-life advantages compared with dialysis. But for patients seeking transplant who are highly sensitized, waiting times have traditionally been long and options limited. We present the case of a 34-year-old hypersensitized female who underwent renal retransplantation. Histocompatibility tests revealed a calculated panel-reactive antibody of 99.53% with multiple antibodies against class I and II human leucocyte antigens and an eplet analysis was performed. The donor’s potential unacceptable antigens were re-defined and the calculated panel-reactive antibody decreased to 88.38%. After one month the patient received a deceased-donor kidney transplant. Complement dependent cytotoxicity crossmatch was negative; virtual crossmatch and flow cytometry crossmatch with historical serum were positive. High-dose intravenous immunoglobulin and rituximab were added to the thymoglobulin-based induction immunosuppression. Three donor-specific antibodies were detected and plasmapheresis was performed. Renal allograft biopsy revealed no manifestations of rejection. Repeated testing observed a decrease in donor-specific antibodies median fluorescence intensity values. Four months post-transplant, the patient remained with normal graft function without proteinuria. She is receiving a standard maintenance immunosuppression regime with prednisolone, mycophenolate mofetil and tacrolimus. The careful discussion among the transplantation center and histocompatibility laboratory in association with intense immunosuppression and close laboratory monitoring allowed a successful human leukocyte antigen-incompatible deceased donor kidney transplantation in the most critical phase for the occurrence of humoral rejection. It is noteworthy that the new histocompatibility and immunogenetics methodologies provide a more affirmative and comprehensive assessment of mismatch acceptability. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692022000400260&lng=pt&nrm=iso&tlng=pt ABSTRACT Renal involvement is a common and severe feature of ANCA-associated vasculitis, leading to end-stage kidney disease and death in a considerable number of patients. One of the challenges of ANCA-associated glomerulonephritis is to establish histological features of prognostic value, in order to identify patients who will benefit of immunosuppression. Although the prognostic value of the renal biopsy in ANCA-associated glomerulonephritis is widely recognized, there is no consensus regarding its pathologic classification. In 2010, Berden et al (J Am Soc Nephrol. 2010; 21: 1628-36) proposed a histopathologic classification based only on glomerular morphology, which is of prognostic value for short-term and long-term renal outcomes. However, over the last years, the results of several studies using multivariable approaches have suggested that the proposed histopathologic classes alone might not be sufficient to predict renal outcome. In order to refine the prognosis of patients with ANCA-associated vasculitis, in 2018, Brix et al (Kidney Int. 2018;94:1177-88) proposed the Renal Risk Score, based on clinical and pathological parameters. In this review, we discuss the prognostic value of the Histopathologic Classification and the Renal Risk Score and their role in routine clinical practice.