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Introduction: Rituximab (RTX) has been reported as an effective treatment alternative in primary forms of minimal change disease (MCD) and focal segmental glomerulosclerosis (FSGS) associated with steroid dependence and frequent relapses. However, the optimal RTX regimen and the outcomes of further doses of RTX remain unclear. This study aimed to evaluate the use of induction and maintenance RTX therapy for adults with primary podocytopathies. Methods: We performed a retrospective case series on adult patients with steroid-dependent podocytopathies who received an induction RTX therapy. Maintenance therapy was performed at physician’s discretion. Remission and relapse rates, concomitant corticosteroids and immunosuppressants use, B-cell depletion and adverse events were analyzed. Results: Fourteen patients (mean age at start of RTX 29.1 ± 21.9 years) with MCD (n = 7) or FSGS (n = 7) were treated with 2 doses of 1,000 mg 2 weeks apart (n = 13) or four doses of 375 mg/m2 (n = 1) of RTX. At last follow-up (mean 47.3 ± 101.7 months), 10 patients were in complete remission and two remained in partial remission. A reduction in the number of relapses, number of patients under corticosteroids and immunosuppressants, and dose of prednisolone was observed when compared to baseline (14 [100%] vs. 5 [35.7%]; 8/14 [57.1%] vs. 4/12 [33.3%]; 13/14 [92.9%] vs. 7/12 [58.3%]; 20 mg/day vs. 5.25 mg/day, respectively). Maintenance RTX therapy was used in 6 patients, with sustained complete remission. Infusion reactions were observed in 4 patients (one required treatment withdrawal). Conclusions: Our findings support the use of RTX for a steroid-free remission in podocytopathies and suggest that maintenance RTX is well-tolerated and associated with prolonged remission. Further studies are needed to confirm its efficacy and safety and establish the optimal induction and maintenance RTX regimen in steroid-dependent podocytopathies.

Introduction: Delayed graft function (DGF), an outcome for which inflammation is critical, has been associated with worse outcomes after kidney transplantation (KT). The neutrophil to lymphocyte and platelet (NLP) ratio is a biomarker of systemic inflammation. We assessed postoperative NLP ratio applicability as an early predictor of DGF in KT patients. Methods: Retrospective cohort of adult patients submitted to KT at our unit, between 1 January 2010 and 31 December 2020. NLP was calculated at 24 hours post-KT. Primary outcome was development of DGF. Logistic regression was calculated to determine significant factors which may have contributed to DGF. Results: We included 527 patients with a mean age of 49.9 ± 12.8 years. In 47.8% of patients expanded criteria donors were used, and in 3.6% non-heart-beating donors. DGF occurred in 17.8% of patients. Mean post-KT NLP was higher in patients submitted to induction therapy with lymphocyte depleting antibodies (50.2±40.3 vs 11.9±7.4 with basiliximab, p

Introduction: In chronic kidney disease (CKD) patients, the risk of kidney replacement therapy (KRT) is highly variable. In 2011, Tangri et al. developed the kidney failure risk equations (KFRE) to predict the 2 and 5-year probability of requiring kidney replacement therapy (KRT). The KFRE is an easily calculated 4-variable equation which has been extensively validated in multiple cohorts. The aim of this study was to validate this risk score in a Portuguese cohort. Methods: We conducted a retrospective analysis of CKD patients stage 3–5 referred for nephrology consult at Centro Hospitalar Universitário Lisboa Norte during the first 6 months of 2018. Age, gender, estimated glomerular filtration rate (eGFR) and albuminuria were assessed. The 4-variable kidney failure risk equation (KFRE) calibrated to a non-North American population was calculated. Requirement of KRT was assessed in a 2-year follow-up. We assessed the Cox logistic regression method of the KFRE to predict KRT requirement and the discriminatory ability was determined using the receiver operating characteristic (ROC) curve. A cut-off value was defined as that with the highest validity. Results: 360 patients were included and 54.4% were male. Mean age was 74.9 ± 12.2 years, serum creatinine was 1.97 ± 0.84 mg/dL, eGFR was 33.4 ± 12.13 ml/min/1.73 m2 and albuminuria was 571.1 ± 848.3 mg/g. Mean calculated risk score was 6.2 ± 11.2%. Twenty-three patients required KRT (6.4%) in the two-year follow-up. The hazard ratio was 1.1 [95% CI (1.06–1.12), p 4.5% for 2-year nephrologist referral, with an hazard ratio of HR 26.7 [95% CI (6.15–116.3), p 4,5% para la derivación al nefrólogo de 2 años, con un índice de riesgo de HR 26,7 (IC del 95%: 6,15-116,3; p

Introduction: In chronic kidney disease (CKD) patients, the risk of kidney replacement therapy (KRT) is highly variable. In 2011, Tangri et al. developed the kidney failure risk equations (KFRE) to predict the 2 and 5-year probability of requiring kidney replacement therapy (KRT). The KFRE is an easily calculated 4-variable equation which has been extensively validated in multiple cohorts. The aim of this study was to validate this risk score in a Portuguese cohort. Methods: We conducted a retrospective analysis of CKD patients stage 3–5 referred for nephrology consult at Centro Hospitalar Universitário Lisboa Norte during the first 6 months of 2018. Age, gender, estimated glomerular filtration rate (eGFR) and albuminuria were assessed. The 4-variable kidney failure risk equation (KFRE) calibrated to a non-North American population was calculated. Requirement of KRT was assessed in a 2-year follow-up. We assessed the Cox logistic regression method of the KFRE to predict KRT requirement and the discriminatory ability was determined using the receiver operating characteristic (ROC) curve. A cut-off value was defined as that with the highest validity. Results: 360 patients were included and 54.4% were male. Mean age was 74.9 ± 12.2 years, serum creatinine was 1.97 ± 0.84 mg/dL, eGFR was 33.4 ± 12.13 ml/min/1.73 m2 and albuminuria was 571.1 ± 848.3 mg/g. Mean calculated risk score was 6.2 ± 11.2%. Twenty-three patients required KRT (6.4%) in the two-year follow-up. The hazard ratio was 1.1 [95% CI (1.06–1.12), p 4.5% for 2-year nephrologist referral, with an hazard ratio of HR 26.7 [95% CI (6.15–116.3), p 4,5% para la derivación al nefrólogo de 2 años, con un índice de riesgo de HR 26,7 (IC del 95%: 6,15-116,3; p

Introduction: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have shown positive renal outcomes in diabetic patients. There is also emerging evidence in non-diabetic patients. This review was conducted to analyse the renal outcomes of SGLT2i in patients without diabetes mellitus (DM). Methods: A systematic review was performed in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) compliant manner. We included only randomized trials that examined the effect of SGLT2i on renal outcomes in non-diabetic patients. Results: A total of ten randomized trials were included with a combined cohort of 26 298 patients. There was a tendency for lesser risk of adverse renal outcomes in heart failure (HF) patients with reduced ejection fraction (EF) (hazard ratio (HR) 0.50-0.71). Lesser effect on adverse renal outcomes was seen in HF patients with preserved EF (HR 0.95). For both preserved and reduced EF HF, there was a statistically significant reduction in the rate of decline in estimated glomerular filtration rate (eGFR) (p

AbstractBackground The first few months of hemodialysis (HD) are associated with a higher risk of mortality. Protein-energy malnutrition is a demonstrated major risk factor for mortality in this population. The C-Reactive Protein to Albumin ratio (CAR) has also been associated with increased mortality risk. The aim of this study was to determine the predictive value of CAR for six-month mortality in incident HD patients.Methods Retrospective analysis of incident HD patients between January 2014 and December 2019. CAR was calculated at the start of HD. We analyzed six-month mortality. A Cox regression was performed to predict six-month mortality and the discriminatory ability of CAR was determined using the receiver operating characteristic (ROC) curve.Results A total of 787 patients were analyzed (mean age 68.34 ± 15.5 years and 60.6% male). The 6-month mortality was 13.8% (n = 109). Patients who died were significantly older (p

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

Introduction: Dysproteinemia is associated with kidney damage and treatment of underlying conditions is crucial to minimize kidney damage. The aim of this study was to describe and analyze the characteristics and outcome of the patients diagnosed with dysproteinemia-associated kidney disease with initial renal presentation. Methods: We performed a retrospective observational study of the patients admitted with initial dysproteinemia-associated kidney disease in the Department of Nephrology and Renal Transplantation at Centro Hospitalar Universitário Lisboa Norte in Lisbon over five years. Results: Thirty patients were diagnosed with dysproteinemia-associated kidney disease: twenty-six (86.7%) with multiple myeloma, one of these with concomitant amyloidosis; three (10.0%) with gammopathy of renal significance and one (3.0%) with Waldenström macroglobulinemia. Mean age was 71.5 (± 12.44) years and half patients were male. Anemia, hypercalcemia, hyperphosphatemia, and hypoalbuminemia was found in twenty-three (76.7%), ten (30.0%), fourteen (46.7%) and seventeen (56.7%) patients, respectively. Bence Jones proteinuria was found in twenty-one (70.0%) patients and thirteen (43.3%) patients presented with creatinine >6 mg/dL. Twelve (40.0%) patients were submitted to kidney biopsy and light chain cast nephropathy was the most common finding. Twenty-nine (96.7%) patients were treated with chemotherapy. Twenty-two (72.3%) patients required renal replacement therapy and six of these (27.3%) patients were submitted to high cut-off dialyzers. Four (13.3%) patients had full recovery of renal function, sixteen (53.3%) remained dialysis-dependent at hospital discharge. At one-year follow-up, eleven (36.7%) patients remained dialysis-dependent and six (20.0%) had died. Conclusion: Dysproteinemia-associated kidney disease can present heterogeneously, and diagnostic suspicion is crucial to start prompt directed therapy to improve kidney and overall outcomes. Renal replacement therapy requirement and dependence at discharge appear to be related to higher mortality in these patients. In the future, routine screening of dysproteinemia may be particularly relevant in older patients to prevent irreversible kidney damage.

Introduction: The incidence of acute kidney injury (AKI) in coronavirus disease 2019 (COVID-19) patients ranges from 0.5% to 35% and has been associated with worse prognosis. The purpose of this study was to evaluate the incidence, severity, duration, risk factors and prognosis of AKI in hospitalized patients with COVID-19. Methods: We conducted a retrospective single-center analysis of 192 hospitalized COVID-19 patients from March to May of 2020. AKI was diagnosed using the Kidney Disease Improving Global Outcome (KDIGO) classification based on serum creatinine (SCr) criteria. Persistent and transient AKI were defined according to the Acute Disease Quality Initiative (ADQI) workgroup definitions. Results: In this cohort of COVID-19 patients, 55.2% developed AKI (n = 106). The majority of AKI patients had persistent AKI (n = 64, 60.4%). Overall, in-hospital mortality was 18.2% (n = 35) and was higher in AKI patients (28.3% vs. 5.9%, p

Introduction: The incidence of acute kidney injury (AKI) in coronavirus disease 2019 (COVID-19) patients ranges from 0.5% to 35% and has been associated with worse prognosis. The purpose of this study was to evaluate the incidence, severity, duration, risk factors and prognosis of AKI in hospitalized patients with COVID-19. Methods: We conducted a retrospective single-center analysis of 192 hospitalized COVID-19 patients from March to May of 2020. AKI was diagnosed using the Kidney Disease Improving Global Outcome (KDIGO) classification based on serum creatinine (SCr) criteria. Persistent and transient AKI were defined according to the Acute Disease Quality Initiative (ADQI) workgroup definitions. Results: In this cohort of COVID-19 patients, 55.2% developed AKI (n = 106). The majority of AKI patients had persistent AKI (n = 64, 60.4%). Overall, in-hospital mortality was 18.2% (n = 35) and was higher in AKI patients (28.3% vs. 5.9%, p

Introduction: Portugal is one of the European Union countries with the lowest rate of Physical Activity (PA), with only 40% of the population being active. During the university period, there is a coincidence of increased autonomy and decision-making among students, and changes in life habits, usually associated with a decrease in PA practice. In percentage terms, 30% of university students are considered physically inactive. There are few studies on PA levels in higher education students, namely in the Physiotherapy course, and even less that relate this topic to the imposed containment measures, due to the COVID-19 pandemic. Objective: Description and comparison of the PA levels of students enrolled in the 1st year of a Physiotherapy Degree, in the academic year 2019/2020. Understand if there are differences in the practice of PA, at different times of the school year, one of which is the lockdown period. Methods: Data were collected using the “International Physical Activity Questionnaire” (IPAQ). It was shared in 3 moments (academic period without evaluations, exam period and lockdown), being a longitudinal study. Results: Physiotherapy students seem to be active regarding the parameter of PA frequency. With the lockdown, there was an increase in the level of PA in 20% of students compared to the school period without assessments, with 14.3% being raised to a high level of PA. The high percentage of students (42.9%) who maintained a high PA level should be highlighted. There was a significant difference from the 1st to the 2nd moment, at the IPAQ level, with a decrease in PA (p = 0.03) with the exam period. Discussion: In the exams period, although the workload is less, there seems to have been a decrease in PA levels. In the lockdown, aspects are presumed to have been removed, which in a normal situation would compromise the practice of PA, leading to better results in some of the variables. The lockdown doesn’t appear to have had a negative impact on PA. Conclusion: The objective of this study was achieved, establishing a starting point for the assessment of PA levels, in university students, in the period of COVID-19. As the sample is composed of future health professionals, it’s important that they be the first to adopt an active lifestyle, thus promoting it.

Introduction: Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) is a multisystemic disease. Despite the improvement in mortality rate since the introduction of immunosuppression, long-term prognosis is still uncertain not only because of the disease activity but also due to treatment associated adverse effects. The neutrophil-to-lymphocyte ratio (NLR) has been demonstrated as an inflammatory marker in multiple settings. In this study, we aimed to investigate the prognostic ability of the NLR in AAV patients. Methods: We conducted a retrospective analysis of the clinical records of all adult patients with AVV admitted to the Nephrology and Renal Transplantation Department of Centro Hospitalar Universitário Lisboa Norte from January 2006 to December 2019. NLR was calculated at admission. The outcomes measured were severe infection at 3 months and one-year mortality. The prognostic ability of the NLR was determined using the receiver operating characteristic (ROC) curve. A cut-off value was defined as that with the highest validity. All variables underwent univariate analysis to determine statistically significant factors that may have outcomes. Only variables which significantly differed were used in the multivariate analysis using the logistic regression method. Results: We registered 45 cases of AVV. The mean age at diagnosis was 67.5 ± 12.1 years and 23 patients were male. The mean Birmingham Vasculitis Activity Score (BVAS) at presentation was 26.0 ± 10.4. Twenty-nine patients were ANCA-MPO positive, 7 ANCA-PR3 positive and 9 were considered negative ANCA vasculitis. At admission, mean serum creatinine (SCr) was 4.9 ± 2.5 mg/dL, erythrocyte sedimentation rate (ESR) was 76.9 ± 33.8 mm/h, hemoglobin was 9.5 ± 1.7 g/dL, C-reactive protein was 13.2 ± 5.8 mg/dL and NLR was 8.5 ± 6.8. Thirty-five patients were treated with cyclophosphamide, eight patients with rituximab for induction therapy. Twenty patients developed severe infection within the first three months after starting induction immunosuppression. In a multivariate analysis, older age (73.6 ± 10.5 vs. 62.6 ± 11.3, p = 0.002, adjusted OR 1.08 [95% CI 1.01–1.16], p = 0.035) and higher NLR (11.9 ± 7.4 vs. 5.9 ± 5.0, p = 0.002, adjusted OR 1.14 [95% CI 1.01–1.29], p = 0.035) were predictors of severe infection at 3 months. NLR ≥4.04 predicted severe infection at 3 months with a sensitivity of 95% and specificity of 52% and the AUROC curve was 0.0794 (95% CI 0.647–0.900). Nine patients died within the first year. Severe infection at 3 months was independently associated with mortality within the first year (OR 6.19 [95% CI 1.12–34.32], p = 0.037). Conclusions: NLR at diagnosis was an independent predictor of severe infection within the first 3 months after immunosuppression start, and severe infection within the first three months was consequently correlated with one-year mortality. NLR is an easily calculated and low-cost laboratory inflammation biomarker and can prove useful in identifying AAV patients at risk of infection and poorer prognosis. Resumen: Introducción: La vasculitis asociada a anticuerpos (VAA) contra citoplasma de neutrófilos es una enfermedad multisistémica. A pesar de la mejora de la tasa de mortalidad desde la introducción de la inmunosupresión, el pronóstico a largo plazo sigue siendo incierto no solo por la actividad de la enfermedad sino también por los efectos adversos asociados al tratamiento. Se ha demostrado que la proporción entre neutrófilos y linfocitos (PNL) es un marcador de inflamación en varios contextos. En este estudio se propuso investigar la capacidad de pronóstico de la PNL en pacientes con VAA. Métodos: Se realizó un análisis retrospectivo de las historias clínicas de todos los pacientes adultos con VAA ingresados en el Departamento de Nefrología y Trasplante Renal del Centro Hospitalario Universitario Lisboa Norte entre enero de 2006 y diciembre de 2019. La PNL se calculó en el momento del ingreso. Los resultados medidos fueron la infección grave a los 3 meses y la mortalidad al año. La capacidad de pronóstico de la PNL se determinó utilizando la curva de características operativas del receptor (COR). Se definió un valor de corte como el de mayor validez. Todas las variables se sometieron a un análisis univariado para determinar los factores estadísticamente significativos que pueden tener resultados. En el análisis multivariado se utilizaron solo las variables que diferían significativamente, empleando el método de regresión logística. Resultados: Se registraron 45 casos de VAA. La edad media en el momento del diagnóstico era de 67,5 ± 12,1 años y 23 pacientes eran hombres. La media de la puntuación de actividad de la vasculitis de Birmingham (BVAS) en el momento de la presentación era de 26,0 ± 10,4. Veintinueve pacientes dieron positivo en MPO-ANCA, 7 dieron positivo en PR3-ANCA y 9 dieron negativo en vasculitis asociada a ANCA. En el momento del ingreso, el nivel de creatinina sérica (SCr) media era de 4,9 ± 2,5 mg/dl, la velocidad de sedimentación globular (VSG) era de 76,9 ± 33,8 mm/h, el nivel de hemoglobina era de 9,5 ± 1,7 g/dl, el nivel de proteína C reactiva era de 13,2 ± 5,8 mg/dl y la PNL era de 8,5 ± 6,8. Treinta y cinco pacientes se trataron con ciclofosfamida y 8 con rituximab para un tratamiento de inducción. Veinte pacientes desarrollaron una infección grave en los primeros 3 meses después de iniciar la inmunosupresión por inducción. En un análisis multivariado, una edad superior (73,6 ± 10,5 frente a 62,6 ± 11,3, p = 0,002, OR ajustado 1,08 [IC del 95%: 1,01-1,16], p = 0,035) y una PNL superior (11,9 ± 7,4 frente a 5,9 ± 5,0, p = 0,002, OR ajustado 1,14 [IC del 95%: 1,01-1,29], p = 0,035) fueron indicadores de una infección grave a los 3 meses. Una PNL ≥ 4,04 predijo una infección grave a los 3 meses con una sensibilidad del 95% y una especificidad del 52% y la curva AUROC fue de 0,0794 (IC del 95%: 0,647-0,900). Nueve pacientes fallecieron en el primer año. La infección grave a los 3 meses estaba asociada de manera independiente a la mortalidad en el primer año (OR 6,19 [IC del 95%: 1,12-34,32], p = 0,037). Conclusiones: La PNL en el momento del diagnóstico fue un indicador independiente de la infección grave en los primeros 3 meses después del inicio de la inmunosupresión. La infección grave en los primeros 3 meses se correlacionó como consecuencia con la mortalidad al año. La PNL es un biomarcador de inflamación para pruebas analíticas fácil de calcular y de bajo coste, y puede resultar útil para identificar a los pacientes con VAA que corren riesgo de contraer una infección y tienen un pronóstico más desfavorable.

Introduction: Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) is a multisystemic disease. Despite the improvement in mortality rate since the introduction of immunosuppression, long-term prognosis is still uncertain not only because of the disease activity but also due to treatment associated adverse effects. The neutrophil-to-lymphocyte ratio (NLR) has been demonstrated as an inflammatory marker in multiple settings. In this study, we aimed to investigate the prognostic ability of the NLR in AAV patients. Methods: We conducted a retrospective analysis of the clinical records of all adult patients with AVV admitted to the Nephrology and Renal Transplantation Department of Centro Hospitalar Universitário Lisboa Norte from January 2006 to December 2019. NLR was calculated at admission. The outcomes measured were severe infection at 3 months and one-year mortality. The prognostic ability of the NLR was determined using the receiver operating characteristic (ROC) curve. A cut-off value was defined as that with the highest validity. All variables underwent univariate analysis to determine statistically significant factors that may have outcomes. Only variables which significantly differed were used in the multivariate analysis using the logistic regression method. Results: We registered 45 cases of AVV. The mean age at diagnosis was 67.5 ± 12.1 years and 23 patients were male. The mean Birmingham Vasculitis Activity Score (BVAS) at presentation was 26.0 ± 10.4. Twenty-nine patients were ANCA-MPO positive, 7 ANCA-PR3 positive and 9 were considered negative ANCA vasculitis. At admission, mean serum creatinine (SCr) was 4.9 ± 2.5 mg/dL, erythrocyte sedimentation rate (ESR) was 76.9 ± 33.8 mm/h, hemoglobin was 9.5 ± 1.7 g/dL, C-reactive protein was 13.2 ± 5.8 mg/dL and NLR was 8.5 ± 6.8. Thirty-five patients were treated with cyclophosphamide, eight patients with rituximab for induction therapy. Twenty patients developed severe infection within the first three months after starting induction immunosuppression. In a multivariate analysis, older age (73.6 ± 10.5 vs. 62.6 ± 11.3, p = 0.002, adjusted OR 1.08 [95% CI 1.01–1.16], p = 0.035) and higher NLR (11.9 ± 7.4 vs. 5.9 ± 5.0, p = 0.002, adjusted OR 1.14 [95% CI 1.01–1.29], p = 0.035) were predictors of severe infection at 3 months. NLR ≥4.04 predicted severe infection at 3 months with a sensitivity of 95% and specificity of 52% and the AUROC curve was 0.0794 (95% CI 0.647–0.900). Nine patients died within the first year. Severe infection at 3 months was independently associated with mortality within the first year (OR 6.19 [95% CI 1.12–34.32], p = 0.037). Conclusions: NLR at diagnosis was an independent predictor of severe infection within the first 3 months after immunosuppression start, and severe infection within the first three months was consequently correlated with one-year mortality. NLR is an easily calculated and low-cost laboratory inflammation biomarker and can prove useful in identifying AAV patients at risk of infection and poorer prognosis. Resumen: Introducción: La vasculitis asociada a anticuerpos (VAA) contra citoplasma de neutrófilos es una enfermedad multisistémica. A pesar de la mejora de la tasa de mortalidad desde la introducción de la inmunosupresión, el pronóstico a largo plazo sigue siendo incierto no solo por la actividad de la enfermedad sino también por los efectos adversos asociados al tratamiento. Se ha demostrado que la proporción entre neutrófilos y linfocitos (PNL) es un marcador de inflamación en varios contextos. En este estudio se propuso investigar la capacidad de pronóstico de la PNL en pacientes con VAA. Métodos: Se realizó un análisis retrospectivo de las historias clínicas de todos los pacientes adultos con VAA ingresados en el Departamento de Nefrología y Trasplante Renal del Centro Hospitalario Universitario Lisboa Norte entre enero de 2006 y diciembre de 2019. La PNL se calculó en el momento del ingreso. Los resultados medidos fueron la infección grave a los 3 meses y la mortalidad al año. La capacidad de pronóstico de la PNL se determinó utilizando la curva de características operativas del receptor (COR). Se definió un valor de corte como el de mayor validez. Todas las variables se sometieron a un análisis univariado para determinar los factores estadísticamente significativos que pueden tener resultados. En el análisis multivariado se utilizaron solo las variables que diferían significativamente, empleando el método de regresión logística. Resultados: Se registraron 45 casos de VAA. La edad media en el momento del diagnóstico era de 67,5 ± 12,1 años y 23 pacientes eran hombres. La media de la puntuación de actividad de la vasculitis de Birmingham (BVAS) en el momento de la presentación era de 26,0 ± 10,4. Veintinueve pacientes dieron positivo en MPO-ANCA, 7 dieron positivo en PR3-ANCA y 9 dieron negativo en vasculitis asociada a ANCA. En el momento del ingreso, el nivel de creatinina sérica (SCr) media era de 4,9 ± 2,5 mg/dl, la velocidad de sedimentación globular (VSG) era de 76,9 ± 33,8 mm/h, el nivel de hemoglobina era de 9,5 ± 1,7 g/dl, el nivel de proteína C reactiva era de 13,2 ± 5,8 mg/dl y la PNL era de 8,5 ± 6,8. Treinta y cinco pacientes se trataron con ciclofosfamida y 8 con rituximab para un tratamiento de inducción. Veinte pacientes desarrollaron una infección grave en los primeros 3 meses después de iniciar la inmunosupresión por inducción. En un análisis multivariado, una edad superior (73,6 ± 10,5 frente a 62,6 ± 11,3, p = 0,002, OR ajustado 1,08 [IC del 95%: 1,01-1,16], p = 0,035) y una PNL superior (11,9 ± 7,4 frente a 5,9 ± 5,0, p = 0,002, OR ajustado 1,14 [IC del 95%: 1,01-1,29], p = 0,035) fueron indicadores de una infección grave a los 3 meses. Una PNL ≥ 4,04 predijo una infección grave a los 3 meses con una sensibilidad del 95% y una especificidad del 52% y la curva AUROC fue de 0,0794 (IC del 95%: 0,647-0,900). Nueve pacientes fallecieron en el primer año. La infección grave a los 3 meses estaba asociada de manera independiente a la mortalidad en el primer año (OR 6,19 [IC del 95%: 1,12-34,32], p = 0,037). Conclusiones: La PNL en el momento del diagnóstico fue un indicador independiente de la infección grave en los primeros 3 meses después del inicio de la inmunosupresión. La infección grave en los primeros 3 meses se correlacionó como consecuencia con la mortalidad al año. La PNL es un biomarcador de inflamación para pruebas analíticas fácil de calcular y de bajo coste, y puede resultar útil para identificar a los pacientes con VAA que corren riesgo de contraer una infección y tienen un pronóstico más desfavorable.

Abstract Background: Acute kidney injury (AKI) is a common complication in patients undergoing major abdominal surgery and is associated with considerable morbidity and mortality. Several studies investigating the association between intraoperative urine output and postoperative AKI have shown conflicting results. Here, we investigated the association of intraoperative oliguria with postoperative AKI in a cohort of patients submitted to elective major abdominal surgery. Methods: This was a single-center retrospective analysis of adult patients who underwent elective major abdominal surgery from January 2016 to December 2018. AKI was defined according to the serum creatinine criteria of the KDIGO classification. Intraoperative oliguria was defined as urine output of less than 0.5 mL/kg/h. Risk factors were evaluated using multivariate logistic regression analysis. Results: A total of 165 patients were analyzed. In the first 48 h after surgery the incidence of AKI was 19.4%. Postoperative AKI was associated with hospital mortality (p=0.011). Twenty percent of patients developed intraoperative oliguria. There was no association between preexisting comorbidities and development of intraoperative oliguria. There was no correlation between the type of anesthesia used and occurrence of intraoperative oliguria, but longer anesthesia time was associated with intraoperative oliguria (p=0.007). Higher baseline SCr (p=0.001), need of vasoactive drugs (p=0.007), and NSAIDs use (p=0.022) were associated with development of intraoperative oliguria. Intraoperative oliguria was not associated with development of postoperative AKI (p=0.772), prolonged hospital stays (p=0.176) or in-hospital mortality (p=0.820). Conclusion: In this cohort of patients we demonstrated that intraoperative oliguria does not predict postoperative AKI in major abdominal surgery.

Background: AKI is frequent in critically ill patients, in whom the leading cause of AKI is sepsis. The role of intrarenal and systemic inflammation appears to be significant in the pathophysiology of septic-AKI. The neutrophils to lymphocytes and platelets (N/LP) ratio is an indirect marker of inflammation. The aim of this study was to evaluate the prognostic ability of N/LP ratio at admission in septic-AKI patients admitted to an intensive care unit (ICU). 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. N/LP ratio was calculated as: (Neutrophil count × 100)/(Lymphocyte count × Platelet count). Results: Fifty-two percent of patients were KDIGO stage 3, 25.8% KDIGO stage 2 and 22.3% KDIGO stage 1. A higher N/LP ratio was an independent predictor of increased risk of in-hospital mortality in septic-AKI patients regardless of KDIGO stage (31.59 ± 126.8 vs 13.66 ± 22.64, p = 0.028; unadjusted OR 1.01 (95% CI 1.00–1.02), p = 0.027; adjusted OR 1.01 (95% CI 1.00–1.02), p = 0.015). The AUC for mortality prediction in septic-AKI was of 0.565 (95% CI (0.515–0.615), p = 0.034). Conclusions: The N/LP ratio at ICU admission was independently associated with in-hospital mortality in septic-AKI patients. Resumen: Antecedentes: La LRA es frecuente en pacientes críticos, en quienes la causa principal de LRA es la sepsis. El papel de la inflamación intrarrenal y sistémica parece ser significativo en la fisiopatología de la LRA por sepsis. La relación entre neutrófilos y linfocitos y plaquetas (N/LP) es un marcador indirecto de inflamación. El objetivo de este estudio fue evaluar la capacidad pronóstica de N/LP en el momento del ingreso en pacientes con LRA por sepsis ingresados en una unidad de cuidados intensivos. Métodos: Se trata de un análisis retrospectivo de 399 pacientes con LRA por sepsis ingresados en la Unidad de Medicina Intensiva del Centro Hospitalario Universitario Lisboa Norte, entre enero de 2008 y diciembre de 2014. Se usó la clasificación del Kidney Disease Improving Global Outcomes (KDIGO) para definir la LRA. La relación N/LP se calculó como: (recuento de neutrófilos × 100)/(recuento de linfocitos × recuento de plaquetas). Resultados: El 52% de los pacientes presentaba KDIGO estadio 3, el 25,8% KDIGO estadio 2 y el 22,3% KDIGO estadio 1. Un valor más elevado de N/LP fue un factor pronóstico independiente de mayor riesgo de mortalidad intrahospitalaria en pacientes con LRA por sepsis, independientemente del estadio KDIGO (31,59 ± 126,8 frente a 13,66 ± 22,64, p = 0,028); OR sin ajustar 1,01 (IC del 95%: 1,00-1,02, p = 0,027), OR ajustada 1,01 (IC del 95%: 1,00-1,02, p = 0,015). El AUC para la predicción de mortalidad en la LRA por sepsis fue de 0,565 (IC del 95%: 0,515-0,615, p = 0,034). Conclusiones: La relación N/LP en el momento del ingreso en la unidad de cuidados intensivos se asoció de forma independiente con la mortalidad intrahospitalaria en pacientes con LRA por sepsis.

Abstract Introduction: The use of Rituximab (RTX) in glomerular diseases (GD) has increased in the past years, although it is still only used in a small fraction of patients. Methods: A single center retrospective study of adult patients with membranous nephropathy (MN), focal segmental glomerulosclerosis (FSGS), lupus nephritis (LN), and vasculitis treated with RTX as first or second-line therapy was conducted at our center from 2010 to 2020. Results: We identified 19 patients; 36.8% had MN and 25.0% each had FSGS, LN, and vasculitis. RTX was first-line therapy in 26.3% of patients and in 73.7% it was second-line therapy. Mean follow-up time was 7.7 ± 7.2 years. In MN, 2 patients (28.6%) had complete remission (CR), 2 patients (28.6%) had partial remission (PR), and 3 patients (42.9%) had no response (NR). In FSGS, 2 patients (50.0%) presented CR, 1 patient (25.0%) had no response, and 1 patient had renal deterioration. Two patients (50.0%) had a LN class IV with a CR after RTX, 1 patient with LN class IIIC/V had no response, and 1 patient with LN class II had renal deterioration. In vasculitis, 3 patients (75.0%) presented CR and 1 patient had PR. Infusion reactions were present in 2 patients (10.5%) and one patient had multiple infectious complications. Conclusions: The efficacy of RTX in treating different types of immune-mediated GD has been demonstrated with different response rates, but an overall safe profile. In our case series, the results are also encouraging. Longitudinal studies are needed to better understand the effect of RTX in GD.

Abstract Introduction: COVID-19 is currently a global health issue and an important cause of mortality. Chronic kidney disease (CKD) is one of the risk factors for infection, morbidity and mortality by SARS-CoV-2. In our study, we aimed to evaluate the clinical presentation and outcomes of CKD patients with COVID-19, as well as identify predictors of mortality. Methods: This was a retrospective study of CKD patients admitted in a tertiary-care Portuguese hospital between March and August of 2020. Variables were submitted to univariate and multivariate analysis to determine factors predictive of in-hospital mortality. Results: 130 CKD patients were analyzed (median age 73.9 years, male 60.0%). Hypertension (81.5%), cardiovascular disease (36.2%), and diabetes (54.6%) were frequent conditions. Cough, dyspnea, fever and respiratory failure were also common. Almost 60% had anemia, 50% hypoalbuminemia, 13.8% hyperlactacidemia and 17% acidemia. Mean serum ferritin was 1531 µg/L, mean CRP 8.3 mg/dL and mean LDH 336.9 U/L. Most patients were treated with lopinavir/ritonavir, hydroxychloroquine or corticosteroids and only 2 with remdesivir. Eighty percent had acute kidney injury and 16.2% required intensive care unit admission. The 34 patients who died were older and more likely to have heart failure. They had higher neutrophils/lymphocytes ratio, ferritin, lactate, and LDH levels. Multivariate analysis identified an association between older age [OR 1.1 (CI 1.01-1.24), p=0.027], higher ferritin [OR 1.0 (CI 1.00-1.00), p=0.009] and higher LDH levels [OR 1.0 (CI 1.00-1.01), p=0.014] and mortality. Conclusion: In our cohort of CKD patients with COVID-19, older age, higher ferritin, and higher LDH levels were independent risk factors for mortality.

Abstract Acute kidney injury (AKI) is a complex syndrome defined by a decrease in renal function. The incidence of AKI has raised in the past decades, and it is associated with negative impact in patient outcomes in the short and long term. Considering the impact of AKI on patient prognosis, research has focused on methods to assess patients at risk for developing AKI, diagnose subclinical AKI, and on prevention and treatment strategies, for which it is crucial an understanding of pathophysiology the of AKI. In this review, we discuss the use of easily available parameters found in a complete blood count to detect patients at risk for developing AKI, to provide an early diagnosis of AKI, and to predict associated patient outcomes.

Abstract Background Surgery is one of the leading causes of acute kidney injury (AKI) in hospitalized patients. Major abdominal surgery has the second higher incidences of AKI, after cardiac surgery. AKI results from a complex interaction between hemodynamic, toxic and inflammatory factors. The pathogenesis of AKI following major abdominal surgery is distinct from cardiac and vascular surgery. The neutrophil, lymphocytes and platelets (N/LP) ratio has been demonstrated as an inflammatory marker and an independent predictor for AKI and mortality after cardiovascular surgery. The aim of this study was to evaluate the prognostic ability of the post-operative N/LP ratio after major abdominal surgery. Methods We cross-examined data of a retrospective analysis of 450 patients who underwent elective or urgent major nonvascular abdominal surgery at the Department of Surgery II of Centro Hospitalar Lisboa Norte from January 2010 to February 2011. N/LP ratio was determined using maximal neutrophil counts and minimal lymphocyte and platelet counts in the first 12 h after surgery. AKI was considered when developed within 48 h after surgery. Results One-hundred and one patients (22.4%) developed AKI. Patients with higher N/LP ratio had an increased risk of developing postoperative AKI (6.36 ± 7.34 vs 4.33 ± 3.36, p

Although the prognostic effect of obesity has been studied in critically ill patients its impact on outcomes of septic patients and its role as a risk factor for acute kidney injury (AKI) is not consensual. We aimed to analyze the impact of obesity on the occurrence of AKI and on in-hospital mortality in a cohort of critically ill septic patients. This study is retrospective including 456 adult patients with sepsis admitted to the Division of Intensive Medicine of the Centro Hospitalar Lisboa Norte (Lisbon, Portugal) between January 2008 and December 2014. Obesity was defined as a body mass index of 30 kg/m2 or higher. The Kidney Disease Improving Global Outcomes classification was used to diagnose and classify patients developing AKI. AKI occurred in 87.5% of patients (19.5% with stage 1, 22.6% with stage 2 and 45.4% with stage 3). Obese patients developed AKI more frequently than non-obese patients (92.8% versus 85.5%, p = .035; unadjusted OR 2.2 (95% CI: 1.04–4.6), p = .039; adjusted OR 2.31 (95% CI: 1.07–5.02), p = .034). The percentage of obese patients, however, did not differ between AKI stages (stage 1, 25.1%; stage 2, 28.6%; stage 3, 15.4%; p = .145). There was no association between obesity and mortality (p = .739). Of note, when comparing AKI patients with or without obesity in terms of in-hospital mortality there were also no significant differences between those groups (38.4% versus 38.4%, p = .998). Obesity was associated with the occurrence of AKI in critically ill patients with sepsis; however, it was not associated with in-hospital mortality.

Heparin-induced thrombocytopenia (HIT) is a serious and life-threatening complication that occurs in five per cent of patients exposed to heparin. It should be considered in patients with a platelet count 50% decrease from baseline count in association with heparin therapy. Thromboembolic complications develop in 50% of patients. Bleeding is rare as the platelet count nadir typically does not drop below 20 × 109 cells/l. Up to 12% of dialysis patients develop HIT, named haemodialysis-related-heparin-induced thrombocytopenia (HD-HIT), as they are a risk group with continuous exposure to heparin. The definition of HD-HIT is less strict, in the range of a platelet count decrease of 30% and below 150 × 109 cells/l due to the intermittent use of heparin.Heparin cessation and alternative anticoagulation are the key interventions in patients with HIT. In dialysis patients, citrate anticoagulation, heparin-free dialysis or peritoneal dialysis are options that must be considered.The authors describe the presentation, diagnosis, treatment and outcomes of five cases of HD-HIT, and emphasize the importance of an accurate diagnosis and early intervention in order to reduce the mortality risk, which can be as high as 20 per cent. Resumen: La trombocitopenia inducida por heparina (TIH) es una complicación grave y potencialmente mortal que aparece en el 5% de los pacientes expuestos a heparina. Debe considerarse en pacientes con una cifra de plaquetas 50% asociada a tratamiento con heparina. El 50% de los pacientes desarrollan complicaciones tromboembólicas. Se produce hemorragia en raras ocasiones dado que el valor mínimo de la cifra de plaquetas normalmente no desciende por debajo de 20 × 109 células/l. Hasta el 12% de los pacientes en diálisis desarrollan TIH, denominada trombocitopenia inducida por heparina relacionada con hemodiálisis (TIH-RH), puesto que son un grupo de riesgo con exposición continua a heparina. La definición de TIH-RH es menos estricta, dentro de un rango de descenso de la cifra de plaquetas del 30% y por debajo de 150 × 109 células/l debido al uso intermitente de heparina.El cese del tratamiento con heparina y la administración de anticoagulación alternativa son las intervenciones clave en pacientes con TIH. En pacientes en diálisis, la anticoagulación con citrato, la diálisis libre de heparina y la diálisis peritoneal son opciones que deben tenerse en cuenta.Los autores describen la presentación, el diagnóstico, el tratamiento y los desenlaces de 5 casos de TIH-RH y destacan la importancia de un diagnóstico preciso, así como de una intervención temprana con el fin de reducir el riesgo de mortalidad, que puede alcanzar el 20%. Keywords: Heparin, Thrombocytopenia, Dialysis, Palabras clave: Heparina, Trombocitopenia, Diálisis

Heparin-induced thrombocytopenia (HIT) is a serious and life-threatening complication that occurs in five per cent of patients exposed to heparin. It should be considered in patients with a platelet count 50% decrease from baseline count in association with heparin therapy. Thromboembolic complications develop in 50% of patients. Bleeding is rare as the platelet count nadir typically does not drop below 20 × 109 cells/l. Up to 12% of dialysis patients develop HIT, named haemodialysis-related-heparin-induced thrombocytopenia (HD-HIT), as they are a risk group with continuous exposure to heparin. The definition of HD-HIT is less strict, in the range of a platelet count decrease of 30% and below 150 × 109 cells/l due to the intermittent use of heparin.Heparin cessation and alternative anticoagulation are the key interventions in patients with HIT. In dialysis patients, citrate anticoagulation, heparin-free dialysis or peritoneal dialysis are options that must be considered.The authors describe the presentation, diagnosis, treatment and outcomes of five cases of HD-HIT, and emphasize the importance of an accurate diagnosis and early intervention in order to reduce the mortality risk, which can be as high as 20 per cent. Resumen: La trombocitopenia inducida por heparina (TIH) es una complicación grave y potencialmente mortal que aparece en el 5% de los pacientes expuestos a heparina. Debe considerarse en pacientes con una cifra de plaquetas 50% asociada a tratamiento con heparina. El 50% de los pacientes desarrollan complicaciones tromboembólicas. Se produce hemorragia en raras ocasiones dado que el valor mínimo de la cifra de plaquetas normalmente no desciende por debajo de 20 × 109 células/l. Hasta el 12% de los pacientes en diálisis desarrollan TIH, denominada trombocitopenia inducida por heparina relacionada con hemodiálisis (TIH-RH), puesto que son un grupo de riesgo con exposición continua a heparina. La definición de TIH-RH es menos estricta, dentro de un rango de descenso de la cifra de plaquetas del 30% y por debajo de 150 × 109 células/l debido al uso intermitente de heparina.El cese del tratamiento con heparina y la administración de anticoagulación alternativa son las intervenciones clave en pacientes con TIH. En pacientes en diálisis, la anticoagulación con citrato, la diálisis libre de heparina y la diálisis peritoneal son opciones que deben tenerse en cuenta.Los autores describen la presentación, el diagnóstico, el tratamiento y los desenlaces de 5 casos de TIH-RH y destacan la importancia de un diagnóstico preciso, así como de una intervención temprana con el fin de reducir el riesgo de mortalidad, que puede alcanzar el 20%. Keywords: Heparin, Thrombocytopenia, Dialysis, Palabras clave: Heparina, Trombocitopenia, Diálisis

Diarrhoea is a common complication after renal transplant and has a significant impact on quality of life, graft function, and mortality. The main causes of post-transplant diarrhoea are infectious and pharmacological. Mycophenolate mofetil (MMF) is an immunosuppressive medication widely used in kidney transplantation patients. Gastrointestinal side effects of MMF, such as nausea, vomiting, diarrhoea, and abdominal pain, mostly occur during the first months of treatment; however, late-onset diarrhoea does not exclude the diagnosis of MMF-induced colitis. MMF-induced colitis is associated with a wide histological spectrum, including inflammatory bowel disease-like, graft versus host disease-like, and ischaemia-like changes, which may lead to misdiagnosis. The complexity and severity of histological features might explain the variation in treatment response. Given the differences in the therapeutic management and prognosis of these histological changes, it is crucial to consider the diagnosis of MMF-induced colitis. The aim of this paper is to report a rare case of late-onset MMF-induced colitis with graft versus host disease-like features in a renal transplant patient who did not respond to MMF therapy withdrawal, and provide a review of data on this rare complication of immunosuppression.

Abstract Acute kidney injury (AKI) is a common complication in patients undergoing major abdominal surgery. Various recent studies using modern standardized classifications for AKI reported a variable incidence of AKI after major abdominal surgery ranging from 3 to 35%. Several patient-related, procedure-related factors and postoperative complications were identified as risk factors for AKI in this setting. AKI following major abdominal surgery has been shown to be associated with poor short- and long-term outcomes. Herein, we provide a contemporary and critical review of AKI after major abdominal surgery focusing on its incidence, risk factors, pathogeny and outcomes.

Multiple myeloma (MM) is a plasma cell disorder that represents almost 10% of haematologic malignancies. Renal impairment, one of the most common complications of MM that occurs in 20–50% of patients, can present in a variety of forms and is associated with increased mortality. Myeloma cast nephropathy is the most common cause of kidney disease in MM patients, presenting as acute kidney injury in the majority of patients. The recent introduction of new chemotherapy agents, autologous stem cell transplantation, and the development of novel techniques of light chain removal have been associated with improved renal and patient outcomes in MM patients. Nevertheless, dialysis-dependent patients with MM have higher mortality than other dialysis patients and may be considered for kidney transplantation only if sustained remission has been achieved and sustained for at least 3 years, bearing in mind the risk of disease recurrence. The authors review the most frequent renal manifestations associated with MM, namely myeloma cast nephropathy, light-chain amyloidosis, and monoclonal immunoglobulin deposition disease, focussing on the therapeutic options for acute and chronic kidney disease.

Abstract Mineral bone disorder is a common feature of chronic kidney disease. Lion face syndrome is rare complication of severe hyperparathyroidism in end-stage renal disease patients, which has been less commonly reported due to dialysis and medical treatment advances in the last decade. The early recognition of the characteristic facial deformity is crucial to prompt management and prevent severe disfigurement. The authors present a rare case of severe hyperparathyroidism presenting with lion face syndrome and bone fractures.

Granting the association of lactates with mortality has been largely documented in critically ill patients with sepsis, its association with the development of acute kidney injury (AKI) in this setting is not well established. We aimed to analyze the association of serum lactates at intensive care unit (ICU) admission with the occurrence AKI in a cohort of critically ill septic patients. Materials and methods: This study is retrospective including 457 adult patients with sepsis admitted to the Division of Intensive Medicine of the Centro Hospitalar Lisboa Norte (Lisbon, Portugal) between January 2008 and December 2014. The Kidney Disease Improving Global Outcomes (KDIGO) classification was used to diagnose and classify patients developing AKI within the first week of hospitalization. Logistic regression analysis was employed to determine factors associated with AKI development. Data were expressed as odds ratios (ORs) with 95% confidence intervals (CIs). Statistical significance was defined as a p-value

Abstract Introduction: Acute kidney injury (AKI) has been described in Coronavirus Disease 2019 (COVID-19) patients and is considered a marker of disease severity and a negative prognostic factor for survival. In this study, the authors aimed to study the impact of transient and persistent acute kidney injury (pAKI) on in-hospital mortality in COVID-19 patients. Methods: This was a retrospective observational study of patients hospitalized with COVID-19 in the Department of Medicine of the Centro Hospitalar Universitario Lisboa Norte, Lisbon, Portugal, between March 2020 and August 2020. A multivariate analysis was performed to predict AKI development and in-hospital mortality. Results: Of 544 patients with COVID-19, 330 developed AKI: 166 persistent AKI (pAKI), 164 with transient AKI. AKI patients were older, had more previous comorbidities, had higher need to be medicated with RAAS inhibitors, had higher baseline serum creatine (SCr) (1.60 mg/dL vs 0.87 mg/dL), higher NL ratio, and more severe acidemia on hospital admission, and more frequently required admission in intensive care unit, mechanical ventilation, and vasopressor use. Patients with persistent AKI had higher SCr level (1.71 mg/dL vs 1.25 mg/dL) on hospital admission. In-hospital mortality was 14.0% and it was higher in AKI patients (18.5% vs 7.0%). CKD and serum ferritin were independent predictors of AKI. AKI did not predict mortality, but pAKI was an independent predictor of mortality, as was age and lactate level. Conclusion: pAKI was independently associated with in-hospital mortality in COVID-19 patients but its impact on long-term follow-up remains to be determined.