Scielo RSS http://scielo.pt/rss.php?pid=0872-016920190003&lang=pt vol. 33 num. 3 lang. pt http://scielo.pt/img/en/fbpelogp.gif http://scielo.pt http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692019000300001&lng=pt&nrm=iso&tlng=pt http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692019000300002&lng=pt&nrm=iso&tlng=pt A paradigm shift in the treatment of end-stage kidney disease (ESKD) is urgently needed. New ESKD policies should include integrated and person-centered care that focuses on the individual's preferences, needs, and values for health care. Based on the example of Portugal, a country with a very high number of prevalent in-center hemodialysis patients, the authors reflect on the past and present of ESKD treatment worldwide, trying to summarize the conceptual changes in the efficiency and equity of ESKD treatment. An optimal approach in ESKD management should consider all options for renal replacement therapy, including a comprehensive conservative approach, of which the incidence and prevalence should be reported on a regular basis for each country and for Europe. An active holistic care to patients with ESKD suffering from severe illness or near the end of life, without dialysis or kidney transplant, is still frequently ignored as an option. In cases of frail or very old individuals or in those with multiple co-morbidities or in poor physical condition, conservative treatment should be considered as a firstline option. A proposal of ESKD treatment following the model of classification of CKD is presented. Up-to-date regulations from national health authorities are needed, especially on the priority policy of supportive/palliative care in non-malignant disease, including ESKD. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692019000300003&lng=pt&nrm=iso&tlng=pt Chronic kidney disease (CKD) is commonly associated with normal anion gap metabolic acidosis and its correction has shown multiple benefits, such as improved bone health and nutritional status, a slower progression of CKD and a lower incidence of end-stage renal disease. Kidney Diseases Improving Global Outcomes 2013 recommend maintaining serum bicarbonate concentration in the normal range (≥ 22mEq/L), which is usually accomplished by using a starting dose of 0.5 - 1mEq/kg/day of bicarbonate supplements. Nutritional strategies incorporating base-producing fruits and vegetables might show equal value. In this context, we analyzed the ingredients instead of labels of widely sold bottled water in Portugal to identify the most bicarbonate-rich bottled water which might help mitigate the complications of CKD chronic metabolic acidosis. We included 32 varieties of bottled water sold in Portuguese supermarkets. If a 70kg-adult is advised to ingest a bicarbonate dose of 0.5 - 1 mEq/kg/day, this amount could be supplied by 1 - 2 liters of Frize® per day, approximately the same as in Pedras Salgadas® and Vidago® (1.1 - 2.2 liters). We concluded that, along with nutritional strategies addressing dietary H+ reduction, Portuguese CKD patients with chronic metabolic acidosis could benefit from drinking water brands such as Frize®, Pedras Salgadas® or Vidago®. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692019000300004&lng=pt&nrm=iso&tlng=pt New data on vitamin D has emerged in the last fifteen years and continues to expand practically every day. It's almost impossible to describe its full actions in a short article. In this review only a few aspects of this family of compounds are described, namely its endocrine pathway, and a few of its pleiotropic effects. Some of the known consequences of vitamin D deficiency are listed and special attention is given to its metabolism and the best way to supplement it, according to the author http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692019000300005&lng=pt&nrm=iso&tlng=pt Contrast agents are widely used in ambulatory and hospitalized patients, as a complement to imaging studies, improving diagnostic accuracy. Patients with chronic kidney disease are at increased risk for adverse events related to contrast administration. In this review, we will summarize the current evidence on this topic. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692019000300006&lng=pt&nrm=iso&tlng=pt In Portugal, in 2018, 64.5% of dialysis patients were elderly and nearly a quarter were older than 80 years. Aging is a heterogeneous process: in some patients, there is a marked clinical improvement under renal replacement therapy (RRT) although others show an inexorable functional decline. Despite advances in dialysis, patient mortality rates remain high. These two phenomena have been difficult to understand and it may be difficult to decide which patients may benefit from RRT or conservative care. Comprehensive Geriatric Assessment (CGA) is an instrument used by geriatricians to evaluate functionality and geriatric syndromes, allowing recognition of problems that would not otherwise be identified. It has been used to individualize and tailor therapies. CGA allows frailty identification (the major geriatric syndrome) and might better predict clinical prognosis and interventions' effectiveness. Physical frailty is a multifactorial condition that is common in chronic kidney disease (CKD) patients and its reversibility is hardly predictable when RRT is started so CGA might contribute to a better understanding of frailty in these patients. Therefore, it is possible that CGA application to CKD older patients would contribute to the selection of patients who might benefit the most from RRT and to improve patient clinical condition. This article aims to review geriatric syndromes and frailty in CKD patients, CGA potential to evaluate them and possible models to apply it. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692019000300007&lng=pt&nrm=iso&tlng=pt ABSTRACT Hepatitis C virus (HCV) is widely prevalent worldwide, with an estimated 180 million people infected. Its manifestations are not limited to hepatic disease, as it has widely known immunomodulator and oncogenic effects. Most HCV associated autoimmune and lymphoproliferative diseases have been shown to subside after successful antiviral treatment. However, viral eradication doesn't always equal lymphoma cure. In some cases, the oncogenic effect lasts well beyond viral elimination. Although the new direct anti-viral agents (DAA) have proved to be safe and effective in treating HCV (with sustained viral responses of 91-95%), this treatment has inherent toxicities. Further, immunologic manifestations of HCV-associated diseases, when present, may require broad immunosuppression in association with the antiviral treatment. We present a case that illustrates the complexities of treating these viral mediated immunologic and lymphoproliferative diseases http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692019000300008&lng=pt&nrm=iso&tlng=pt Abstract: Fanconi syndrome is characterized by proximal tubular dysfunction, with inability to reabsorb bicarbonate causing type 2 renal tubular acidosis associated with aminoaciduria, normoglycemic glycosuria, hypophosphatemia with phosphaturia and proteinuria. A 68-year-old man with a history of type 2 diabetes mellitus, high-grade papillary carcinoma of the bladder, submitted to transurethral resection in 2011 and 2013 had prostatic adenocarcinoma diagnosed in 2015 with bone metastasis under zoledronic acid. The patient was referred to the emergency department because of anemia “de novo” and acute on chronic kidney injury. Urinary sediment showed nonnephrotic proteinuria and renal ultrasound was normal. He had hyperchloremic metabolic acidosis with hypokalemia, hypophosphatemia, hypocalcemia, hypouricemia, without glycosuria. No evidence of hemolysis nor abnormalities in serum and urinary immunoelectrophoresis, endoscopic studies, myelogram, or bone marrow biopsy. Renal biopsy was compatible with acute tubular necrosis superimposed on diabetic and hypertensive nephropathy. Zoledronic acid was suspended and we observed slow improvement of renal function and resolution of metabolic acidosis and ionic disorders. Zoledronic acid is nephrotoxic and may induce tubular dysfunction, which can cause Fanconi syndrome. Since 2012, there have been cases relating the administration of zoledronic acid for bone metastasis or hypercalcemia associated with malignant neoplasia with Fanconi syndrome. Although it is a rare association, it is a potentially fatal complication and renal function monitoring is essential. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692019000300009&lng=pt&nrm=iso&tlng=pt Abstract: Fanconi syndrome is characterized by proximal tubular dysfunction, with inability to reabsorb bicarbonate causing type 2 renal tubular acidosis associated with aminoaciduria, normoglycemic glycosuria, hypophosphatemia with phosphaturia and proteinuria. A 68-year-old man with a history of type 2 diabetes mellitus, high-grade papillary carcinoma of the bladder, submitted to transurethral resection in 2011 and 2013 had prostatic adenocarcinoma diagnosed in 2015 with bone metastasis under zoledronic acid. The patient was referred to the emergency department because of anemia “de novo” and acute on chronic kidney injury. Urinary sediment showed nonnephrotic proteinuria and renal ultrasound was normal. He had hyperchloremic metabolic acidosis with hypokalemia, hypophosphatemia, hypocalcemia, hypouricemia, without glycosuria. No evidence of hemolysis nor abnormalities in serum and urinary immunoelectrophoresis, endoscopic studies, myelogram, or bone marrow biopsy. Renal biopsy was compatible with acute tubular necrosis superimposed on diabetic and hypertensive nephropathy. Zoledronic acid was suspended and we observed slow improvement of renal function and resolution of metabolic acidosis and ionic disorders. Zoledronic acid is nephrotoxic and may induce tubular dysfunction, which can cause Fanconi syndrome. Since 2012, there have been cases relating the administration of zoledronic acid for bone metastasis or hypercalcemia associated with malignant neoplasia with Fanconi syndrome. Although it is a rare association, it is a potentially fatal complication and renal function monitoring is essential. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692019000300010&lng=pt&nrm=iso&tlng=pt Abstract: Fanconi syndrome is characterized by proximal tubular dysfunction, with inability to reabsorb bicarbonate causing type 2 renal tubular acidosis associated with aminoaciduria, normoglycemic glycosuria, hypophosphatemia with phosphaturia and proteinuria. A 68-year-old man with a history of type 2 diabetes mellitus, high-grade papillary carcinoma of the bladder, submitted to transurethral resection in 2011 and 2013 had prostatic adenocarcinoma diagnosed in 2015 with bone metastasis under zoledronic acid. The patient was referred to the emergency department because of anemia “de novo” and acute on chronic kidney injury. Urinary sediment showed nonnephrotic proteinuria and renal ultrasound was normal. He had hyperchloremic metabolic acidosis with hypokalemia, hypophosphatemia, hypocalcemia, hypouricemia, without glycosuria. No evidence of hemolysis nor abnormalities in serum and urinary immunoelectrophoresis, endoscopic studies, myelogram, or bone marrow biopsy. Renal biopsy was compatible with acute tubular necrosis superimposed on diabetic and hypertensive nephropathy. Zoledronic acid was suspended and we observed slow improvement of renal function and resolution of metabolic acidosis and ionic disorders. Zoledronic acid is nephrotoxic and may induce tubular dysfunction, which can cause Fanconi syndrome. Since 2012, there have been cases relating the administration of zoledronic acid for bone metastasis or hypercalcemia associated with malignant neoplasia with Fanconi syndrome. Although it is a rare association, it is a potentially fatal complication and renal function monitoring is essential.