Portuguese Journal of Nephrology & Hypertension

Tubulointerstitial Nephritis and TINU syndrome: A rising cause of acute kidney injury

Infectious risk of elderly patients on peritoneal dialysis: Experience of a portuguese center

Background: The goal of this study was to compare the risk of peritoneal dialysis-related infections in younger and older patients and to identify risk factors for infection in elderly patients. Methods: We performed a longitudinal retrospective study on a population of Portuguese peritoneal dialysis patients treated at the same center between January 2005 and December 2015. Clinical and laboratory data were collected from medical reports. Two groups of patients were compared: non elderly (< 65 years) and elderly (≥ 65 years). Results: Among 100 patients, there were 73 non elderly (median age 52 years) and 27 elderly (median age 74 years). Elderly patients were not associated with higher PD-infection rates or with less time to PD-related infections. Cerebrovascular disease was the only significant adverse predictor of peritonitis in elderly (crude HR 3.8; 95% CI 1.10 to 13.34; P = 0.035) and those with higher levels of serum albumin were less likely to developperitonitis (crude HR 0.47 per each g/dl of increase; 95% CI 0.24 to 0.89; P = 0.023). Conclusions: In our study, elderly patients did not present a greater risk for peritonitis or catheter-related infections.

Nutritional assessment of patients with chronic kidney disease under treatment with peritoneal dialysis

Introduction: Peritoneal dialysis is a renal replacement therapy that allows the patient to live with a certain degree of autonomy and flexibility. Nutritional diagnosis is crucial, considering the high prevalence of nutritional disorders amongst this population and its correlation with the clinical prognosis. The aim of the current study is to evaluate the nutritional state of patients receiving peritoneal dialysis. Methodology: This is a cross-sectional study realized with 30 patients undergoing peritoneal dialysis. Data collection was undertaken by scheduling appointments for nutritional assessment in which the following data were collected: anthropometric data, body composition, subjective global assessment, assessment of food consumption by means of 24-hour dietary recall and food frequency questionnaire. Biochemical tests and clinical history were obtained from the patients records. Results: Most patients were in good nutritional state, euvolemic. A positive statistical association was observed regarding phase angle and lean mass. The biochemical examinations showed that albumin, HDL-c and vitamin D levels were below reference values, whilst phosphorus and parathyroid hormone were above the ideal values. While glucose in the dialysate did not present any statistical association with regard to serum glucose, glycated hemoglobin or triglycerides, it demonstrated statistical association in relation to the preservation of somatic muscle mass. Food consumption assessment showed inadequate protein intake. Conclusion: Patients had good nutritional state and statistical association for a satisfactory prognosis, but nutritional follow-up was important in order to avoid complications.

Evaluation of the Portuguese kidney transplant allocation system: comparative results from a simulation

The distribution of such a scarce resource as deceased donor kidneys should be made by observing a balance between fairness, efficiency and flexibility. Before implementing a new kidney allocation system, these principles should be evaluated and assured objectively. In this article we compare the renal transplant donor-recipient pair selection system implemented in Portugal in 2007 with the Eurotransplant (ET) and United Kingdom (UK) systems. We simulated data for 500 waitlist kidney transplant candidates and 70 deceased donors. Each of the 70 donors was allocated to the best pair of listed candidates, taking into account the criteria of the three allocation systems under analysis. Subsequently, we compare the selected candidates groups to kidney transplant. The Portuguese organ allocation model selects candidates with a greater number of incompatibilities with the donor compared to the other two models. Under the Portuguese systems rules, candidates have a greater age difference with the respective donors (median = 12.5 years) than those selected by the ET system (10 years) or the UK system (8 years). The Portuguese model selected more hypersensitized candidates (15%), but this difference was not statistically significant when compared to the percentage of hypersensitized patients selected by the ET model (10.7%). The Portuguese model has less equity than the other two models under analysis, since the observed disadvantages regarding the number of incompatibilities and age differences with the respective donor are not compensated for by the selection of patients with longer time on dialysis.

The challenge of pregnancy after kidney Transplantation

Kidney transplantation restores the impairment in fertility of end-stage renal disease patients. The majority of pregnancies after renal transplantation are sucessful, although there are risks for the mother and for the fetus, related to graft function, rejection, hypertensive disturbances, infections, caesarian deliveries, as well as preterm and low birth weight babies. Immunosuppressive drugs and other medication have to be carefully reviewed before this period, and the timing of conception is also an issue of debate. In this article the author reviews the most recent practices in the medical follow-up of a renal transplanted pregnant woman.

Supportive care in advanced chronic kidney disease: Comprehensive conservative care

Incident and prevalent patients on dialysis are progressively older, with high comorbidity burden and functional dependency. Many could have benefited from a conservative approach, since considerations of symptoms, autonomy, quality of life and hospital-free days are sometimes more important for patients and families than survival. As result, nephrologists around the world are facing challenges to determine which treatment best fits their patients. Comprehensive conservative care in chronic kidney disease care has been recently defined as a holistic, multidisciplinary and patient-centered approach for care of patients with stage 5 CKD. It does not include dialysis, and a shared-decision-making process and advanced care planning are central pillars, providing a way to meet patient and families goals. This review will focus on comprehensive conservative care in CKD in order to provide a communication framework for decision-making process as a guide for nephrologists and other health care professionals.

Supportive care in advanced chronic kidney disease: Withholding and withdrawing dialysis therapy

Over the latest few decades, dialysis has been offered to older and more complex patients. This treatment can increase the symptom burden and also add new symptoms that can have a profound impact in frail and/or elderly patients with multiple comorbidities. A quality of life approach may be more desirable than a quantity of life approach in these cases. Around the world, some countries have endorsed programs of shared decisionmaking process and advanced care planning for end-stage renal disease, with creation of goal-directed protocols. Alignment with palliative care programs to develop structured approaches is the key to successful outcomes. Reforms in medical education are needed to address current necessities in these areas. This article summarizes current knowledge regarding decision making and palliative care in end-stage renal disease.

Pediatric pulmonary embolism and nephrotic syndrome

Thromboembolic complications, such as pulmonary embolism, are well-documented complications in nephrotic syndrome. The authors report a case of a 10-year-old boy with nephrotic syndrome and history of thrombotic complications, who experienced a massive pulmonary embolism during nephrotic syndrome relapse. Clinical signs and symptoms were minimal; D-dimers were an important clue and computed tomography pulmonary angiography established the definitive diagnosis. Treatment with low weight heparin was effective. Screening for hereditary thrombophilia identified predisposition towards thrombosis. Although these events seem rare in children, the literature suggests that they are actually underdiagnosed. Clinicians should be aware of this clinical condition, in order to avoid delay or misdiagnosis and prevent a poor or fatal outcome.

Light and heavy chain deposition disease - Case report

Monoclonal immunoglobulin deposition disease is part of the spectrum of monoclonal gammopathy of renal significance. We report a case of a light and heavy chain deposition disease treated with anti-plasma cell therapy and peripheral blood stem cell transplantation and over 2 years of follow-up

Tubulointerstitial nephritis and uveitis syndrome (TINU) - à propos of 2 cases

The authors present two cases of tubulointerstitial nephritis and uveitis syndrome (TINU). TINU is a well-known yet rarely reported oculorenal inflammatory clinical entity. A high level of suspicion is needed to identify this entity. The first case is that of a 24-year-old female presenting with bilateral red eye and ocular pain. Laboratory investigation revealed renal insufficiency (serum creatinine 4.9mg/dL) and kidney biopsy presented tubulointerstitial nephritis. The second case is that of a 69-year-old female initially diagnosed with uveitis who later presented with general symptoms and renal insufficiency (serum creatinine 3.96 mg/dL) and whose kidney biopsy showed a tubulointerstitial nephritis pattern. Both patients were treated with steroids and renal function improved. It may be worth screening for uveitis in all patients with tubulointerstitial nephritis and evaluating renal function in those presenting with apparent idiopathic uveitis.

Acute tubulointersticial nephritis with uveitis: A report of two cases

Tubulointersticial nephritis and uveitis syndrome is an idiopathic and rare cause of acute kidney injury that should not overlooked, because it usually requires specific therapeutic interventions. We report two distinct cases: a young and an elder female. Both cases presented with unspecific constitutional symptoms but had different onset of renal and ocular involvement. Both were treated with topical and systemic corticoids and although there was a good initial response in both cases, an early relapse after steroids taper was observed in the younger patient and a persistent renal dysfunction in the older one. A high clinical suspicion and understanding of this disease is necessary for an adequate management and treatment of these patients. Recent data associates a worse renal prognosis when the disease appears inadvanced age. In both of our cases the outcome was good but we had a short follow-up. The histological presentation of this disease in our older patient was similar to that reported in the literature, with a high percentage of fibrosis and chronicity of renal tissue that can contribute to the higher grade of renal dysfunction in this type of patients