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Introduction: Kidney transplant (KT) recipients have a high risk for adverse outcomes from infections, such as COVID-19. Methods: We have retrospectively reviewed all KT recipients with documented COVID-19 between March 1, 2020, and March 15, 2021, and analyzed patients’ characteristics, clinical course, treatment, and outcomes. Results: We identified 123 patients, 72% were male, with a mean age of 54.5±13.0 years. Twenty percent were asymptomatic, 7% had a nosocomial transmission, and 36% of the remainder required hospitalization. Almost all admitted patients received oxygen, 30% required invasive mechanical ventilation (IMV), more than a half had acute kidney injury, with 10% requiring dialysis, and 20% died. Incidence was comparable to that of the Portuguese population, but the mortality rate was almost four times higher (SMR of 3.768 (95% CI:1.723-7.154). Higher body mass index (OR 1.275, P=0.001), lower baseline graft function (OR 0.968, P=0.015), and nosocomial transmission (OR 13.836, P=0.019) were associated with oxygen demand, whereas female gender (OR 3.801, P=0.031) and lower baseline kidney graft function (OR 0.955, P=0.005), but not body mass index, were associated with IMV and/or death. Conclusion: Mortality rate in KT patients was higher than in the general population and lower baseline kidney function was the most consistent marker for adverse outcomes. Resumo Introdução: Os receptores de transplante renal (TR) apresentam um alto risco para desfechos adversos de infecções, tais como a COVID-19. Métodos: Revisamos retrospectivamente todos os receptores de TR com COVID-19 documentada entre 1º de Março de 2020 e 15 de Março de 2021, e analisamos as características, curso clínico, tratamento e desfechos dos pacientes. Resultados: Identificamos 123 pacientes, 72% do sexo masculino, com uma média de idade de 54,5±13,0 anos. Vinte por cento eram assintomáticos, 7% apresentaram transmissão nosocomial, e 36% do restante necessitaram de internação. Quase todos os pacientes internados receberam oxigênio, 30% necessitaram de ventilação mecânica invasiva (VMI), mais da metade apresentou lesão renal aguda, com 10% necessitando de diálise, e 20% foram a óbito. A incidência foi comparável à da população portuguesa, mas a taxa de mortalidade foi quase quatro vezes superior (TMP de 3,768 (IC 95%: 1,723-7,154). Maior índice de massa corporal (OR 1,275; P=0,001), menor função do enxerto basal (OR 0,968; P=0,015), e transmissão nosocomial (OR 13,836; P=0,019) foram associados à demanda de oxigênio, enquanto sexo feminino (OR 3,801; P=0,031) e menor função do enxerto renal basal (OR 0,955; P=0,005), mas não índice de massa corporal, foram associados à VMI e/ou óbito. Conclusão: A taxa de mortalidade em pacientes com TR foi mais elevada do que na população em geral e a função renal basal mais baixa foi o marcador mais consistente para desfechos adversos.

Introduction: Ammonia is a resultant molecule from the protein metabolism that can be neurotoxic when present in high concentrations, causing brain edema and encephalopathy. Extracorporeal blood purification technique (EBPT) can play a role in reducing both ammonia and urea blood levels. However, there are no specific guidelines for its use in hyperammonemia, due to its low incidence and scarce literature on this subject, particularly in adults. Case report: The authors describe a case of a 22 -year -old previously healthy woman. She presented with polyuria, polydipsia, anorexia, vomiting and significant (>10%) weight loss over a month. Laboratory data revealed hypoglycemia and a high anion gap metabolic acidosis with severe acidemia with normal lactate, serum creatinine of 1.12 mg/dl and 260 (reference value 26 -74) umol/l of ammonia. Urine analysis showed ketone bodies. She evolved with progressive encephalopathy and neurological deterioration. The hypothesis of hyperammonemic encephalopathy secondary to a hereditary metabolic disease was suspected. Medical supportive therapy was initiated. An EBPT for ammonia removal and acid -base correction was initiated using continuous venovenous hemodiafiltration (CVVHDF) with a drastic neurologic improvement. A fatty acid beta -oxidation deficit was discovered. The patient was discharged with no neurological changes, with a strict diet free of fat, animal protein and high -protein vegetables, plus supplementation with benzoate, carnitine, riboflavin, maltodextrine and essential amino acids. Discussion and conclusion: In adults, hyperammonemia related to metabolic disorders is rare, and in the presence of encephalopathy, ECDT should be considered. Ammonia is easily dialysable either by intermittent or continuous techniques. CVVHDF provides a continuous clearance with less rebound effect.

Background. Identifying trajectories of kidney disease progression in chronic kidney disease (CKD) patients may help to deliver better care. We aimed to identify and characterize trajectories of renal function decline in CKD patients and to investigate their association with mortality after dialysis. Methods. This retrospective cohort study included 378 CKD patients who initiated dialysis (aged 65 years and over) between 2009 and 2016. Were considered mixed models using linear quadratic and cubic models to define the trajectories, and we used probabilistic clustering procedures. Patient characteristics and care practices at and before dialysis were examined by multivariable multinomial logistic regression. The association of these trajectories with mortality after dialysis was examined using Cox models. Results. Four distinct groups of eGFR trajectories decline before dialysis were identified: slower decline (18.3%), gradual decline (18.3%), early rapid decline (41.2%), and rapid decline (22.2%). Patients with rapid eGFR decline were more likely to have diabetes, more cognitive impairment, to have been hospitalized before dialysis, and were less likely to have received pre-dialysis care compared to the patients with a slower decline. They had a higher risk of death within the first and fourth year after dialysis initiation, and after being more than 4 years in dialysis. Conclusions. There are different patterns of eGFR trajectories before dialysis initiation in the elderly, that may help to identify those who are more likely to experience an accelerated decline in kidney function, with impact on pre ESKD care and in the mortality risk after dialysis.

BACKGROUND AND AIMS Kidney transplantation (KT) improves survival and quality of life of patients with end-stage renal disease. However, there is still an unbalance between supply and demand for kidneys. To increase the number of available grafts and reduce the waiting list for transplantation, recruitment of older living donors has expanded. This approach remains controversial for several reasons, including the impact of kidney function decline on long-term graft and recipient survival. We aimed to evaluate the impact of living donor (LD) age on recipient graft survival and on graft function decline over time. METHOD This is a Unicenter retrospective observational study that included kidney transplants of LD between 2008 and 2017. Several clinical data were analyzed, including donors’ comorbidities, immunological features of the transplant, induction immunosuppression, number of acute rejections (AR) at the first year, and the graft glomerular filtration rate (eGFR) during the follow-up period. The eGFR was calculated using the CKD-EPI equation. The LDs were classified as young ( The Kaplan–Meier curves and Cox proportional hazards multivariable regression were used for survival analysis and linear mixed regression was used to evaluate the annual slope of recipient eGFR, comparing both groups. RESULTS We observed 210 LD kidney transplants: 86% (n = 181) from young (D The censored recipient graft survival was similar for D Linear mixed regression showed that recipient eGFR from D ≥60 was lower than D CONCLUSION Although the greater eGFR graft decline in the first 12 months and beyond, we demonstrated that kidneys from older living donors did not significantly compromise the censored recipient graft survival. We did not evaluate the age match between donor and recipient, as has been done in other studies, but even so, these results support the importance of increasingly encouraging KT from older living donors. It can improve the quality of life, compared to the time on dialysis and, especially for old candidates, can be the only chance to get transplanted.

BACKGROUND AND AIMS Mortality in end-stage renal disease remains high, especially among the elderly with a higher burden of comorbidity and frailty. In this group, dialysis (HD) may not offer better survival compared with conservative management. Frailty defined by clinical frailty scale (CFS) and comorbidity by modified Charlson Comorbidity Index (mCCI) are known independent predictors of mortality. Our aim is to compare that has higher impact on early mortality in incident elderly HD patients. METHOD We conducted a retrospective cohort study of patients aged 65 years and over, who started HD as their first renal replacement therapy (RRT) between January 2014 and December 2019. CFS and mCCI, at time of HD start, were used to evaluate, respectively, frailty and comorbid disease burden. The primary outcome was death in the first 6 months of RRT. The optimal cut-off for our outcome was defined through the analysis of a receiver operating characteristic (ROC) curve. Survival curves were constructed using Kaplan–Meier method, with comparison between patients' groups being done by log-rank test. Multivariable Cox analysis was applied to assess independent predictors of early mortality. All p values are two-tailed, p value RESULTS 166 patients were included, 107 (64%) started HD by central venous catheter. The median age, at time of haemodialysis start, was 75 years ± 6.3 years. The mortality at 6 months was 19% (n = 31). For both scales, the analysis of ROC curve, stablished the optimal cut-off to predict the event death at first 6 months of HD as ≥ 5points. The performance of CFS was superior to the mCCI (P = 0.031; Figure 1 top). In fact, the area under the curve is higher in CFS (0.739) versus the mCCI (0.620). A CFS ≥ 5 had a sensitivity/specificity of 94%/44% in prediction the primary outcome. On the other and, a mCCI ≥ 5 predicts the same outcome with a sensitivity/specificity of 26%/88%. The diagnostic odds ratio for CFS ≥ 5 was 11.6, compared with only 2.7 for mCCI ≥ 5. When confronted using the Kaplan–Meier method, both CSF CONCLUSION In this cohort of incident elderly HD patients, frailty defined by CFS was a stronger predictor of mortality than comorbidity defined by CCI. The group of mCCI/CFS (≥5/≥5) has a 10-time higher chance of dying than the reference group. Our data also suggest that simple scores can predict the risk of early mortality in incident HD patients and should be used to guide the decision-making process for elderly patients and to improve the quality of the information given to patients and families.

BACKGROUND AND AIMS The number of elderly patients starting haemodialysis is increasing as a result of an aging population and age-related increases in the incidence of chronic kidney disease. Outcomes of elderly patients with end-stage kidney disease at urgent haemodialysis (UH) initiation are poorly studied. It is necessary to define predictors of adverse outcomes in these population. The aim of this study was to evaluate patterns and predictors of 1-year mortality of urgent-start haemodialysis in elderly patients. METHOD This is an observational, retrospective study including all elderly patients (>65 years) who started UH between 2014 and 2019. The follow-up period was 1 year after the start of UH. Demographic data, comorbidities, analytical parameters and vascular access were recorded. We analyzed global mortality by Kaplan–Meier survival curves and predictors of mortality at 1 year by multivariable Cox regression. In a secondary evaluation, predictors of mortality at 1 year by specific cause were studied through competing-risks multivariable regression. RESULTS A total of 166 patients (75.5 ± 6.3 years) were included and 45 patients (27%) died at 1-year follow-up. One-year mortality rate was 33/100 person-years [95% confidence interval (95% CI): 25–44] with the highest mortality rate in the first trimester (48/100 person-years, 95% CI: 31–75) (Figure 1A). The main cause of mortality was infection (mortality rate 14/100 person-years, 95% CI 9–22) followed by cardiovascular deaths (11/100 person-year, 95% CI 7–18) and cancer (5/100 person-years, 95% CI 2–11). There was a significant difference in the Kaplan–Meier survival probability between the patients with CFS ≥ 5 and CFS 3.2 g/dL, at 3 and 12 months (81% versus 94% and 57% versus 84%, respectively, P Patients who died at 1 year of follow-up were later referred to nephrology (P = 0.031), had lower serum albumin levels (P = 0.001), had a higher Clinical Frailty score—CFS—(P The 1-year mortality predictors that we identified were: CFS ≥ 5 (HR = 10.185; P Predictors of 1-year infection-related death were CFS ≥ 5 (sHR = 9.809; P = 0.024) and serum albumin levels CONCLUSION This study showed a high mortality rate in elderly patients who started UH, especially during the first 3 months. Infectious diseases were the main cause of mortality followed by cardiovascular diseases. The CFS was a useful predictor of mortality in the global analysis and a predictor of mortality caused by infection, cancer or cardiovascular disease; all patients started UH, which can exacerbate the importance of frailty in defining outcomes. Serum albumin is a predictor of mortality by infectious causes, possibly reflecting the inflammatory activity and malnutrition of these patients. The relationship between BMI and outcomes needs further evaluation.

BACKGROUND AND AIMS Living donor kidney transplantation (LDKT) provides the best outcomes of all renal replacement modalities, including survival and quality of life. Studies on the association between pre-donation estimated glomerular filtration rate (eGFR) and graft outcomes have yielded inconsistent results. Two eGFR thresholds are generally used to accept or deny a donor (respectively, ≥90 and METHOD This is a unicentric retrospective observational study that included the LDKT pairs submitted to transplant between 2008 and 2017. We gathered clinical data, including donor's comorbidities, immunological features of the transplant, the occurrence of acute rejection episodes in the first year, and graft eGFR during the follow-up period. For statistical purposes, we split the donors in three groups: group 1, with eGFR ≥90 mL/min/1.73 m2; group 2, eGFR RESULTS We studied 210 donor-recipient pairs. The average age at the time of transplant was 48.0 ± 10.6 years for donors and 41.3 ± 13.3 years for recipients. Pre-donation eGFR was 100.1 ± 14.2 mL/min/1.73 m2 and most donors (78%) were in group 1 (eGFR 105.9 ± 9.4 mL/min/1.73 m2). We found two independent predictors of death censored graft failure: the occurrence of rejection episode(s) during the first year (HR: 4.99, CI: 1.44–17.26, P = 0.011) and having a donor from group 3 (HR: 5.14, CI: 1.49–17.75, P 0% (HR: 3.802, CI: 1.387–10.489, P = 0.010) and donor from group 3 (HR: 3.514, CI: 1.087–11.355, P = 0.036). At 1-year after transplant, the recipients from group 1 had a significantly higher eGFR than patients from group 2, but did not differ from group 3 (respectively, 60.8 versus 54.4 [P CONCLUSION This study suggests that in LDKT, when donors’ eGFR is borderline (

Introduction: It has been suggested that cystatin C levels are modified by obesity and inflammation. Furthermore, cystatin C has been associated with cardiovascular events and mortality outcomes. Aim: To study the association of cystatin C with the metabolic profile and cardiovascular disease of peritoneal dialysis patients. Methods: Data collected included clinical, laboratorial, and multifrequency bioimpedance assessment of 52 stable peritoneal dialysis patients. Minimal residual renal function was defined as > 2mL/min/1.73m2. Results: Serum cystatin C was not significantly associated with peritoneal or urinary cystatin C excretion. Negative correlation of cystatin C with normalized protein catabolic rate (rho -0.33, p = 0.02) and a trend towards positive correlation with relative body fat (rho 0.27, p = 0.05) were not independent from residual renal function. Cystatin C was not significantly associated with cardiovascular disease (p = 0.28), nor with glycated hemoglobin (p = 0.19) or c-reactive protein (p = 0.56). In the multivariate model, both age and diabetes were the strongest predictors of cardiovascular disease (odds ratio 1.09, p = 0.029 and odds ratio 29.95, p = 0.016, respectively), while relative body fat was negatively associated with cardiovascular disease (p = 0.038); neither cystatin C (p = 0.096) nor minimal residual renal function (p = 0.756) reached a significant association with cardiovascular disease. Conclusions: In this group of peritoneal dialysis patients, cystatin C did not correlate with the metabolic or inflammatory status, nor cardiovascular disease, after adjustment for residual renal function. Introdução:: Tem sido sugerido que os níveis de cistatina C são modificados pela obesidade e inflamação. Além disso, a cistatina C tem sido associada a eventos cardiovasculares e desfechos de mortalidade. Objetivo:: Estudar a associação da cistatina C com o perfil metabólico e doença cardiovascular de pacientes em diálise peritoneal. Métodos:: Os dados coletados incluíram avaliação clínica, laboratorial e de bioimpedância múltipla de 52 pacientes estáveis em diálise peritoneal. A função renal residual mínima foi definida como > 2mL/min/1,73m2. Resultados:: A cistatina C sérica não esteve significativamente associada à excreção peritoneal ou urinária. A correlação negativa da cistatina C com a taxa catabólica protéica normalizada (rho -0,33, p = 0,02) e uma tendência de correlação positiva com a gordura corporal relativa (rho 0,27, p = 0,05) não foram independentes da função renal residual. A cistatina C não se associou significativamente à doença cardiovascular (p = 0,28), nem com hemoglobina glicada (p = 0,19) ou proteína C reativa (p = 0,56). No modelo multivariado, idade e diabetes foram os mais fortes preditores de doença cardiovascular (razões de probabilidade 1,09, p = 0,029 e 29,95, p = 0,016, respectivamente) enquanto a gordura corporal relativa se associou negativamente à doença cardiovascular (p = 0,038). A cistatina C não se associou significativamente com doença cardiovascular (p = 0,096), tampouco a função residual mínima (p = 0,756). Conclusão:: Neste grupo de pacientes em diálise peritoneal, a cistatina C não se correlacionou com o estado metabólico ou inflamatório, nem com doença cardiovascular, após ajuste para função renal residual. info:eu-repo/semantics/publishedVersion

Introduction Elderly people represents a vulnerable and increasing population presenting with acute coronary syndrome (ACS). Several data suggest the benefit of an early revascularization in ST-elevation (STE)-ACS or non-STE-ACS with positive troponin. However questions persist considering the unavoidable adverse prognosis, patient's functional and cognitive status, comorbidities and preferences. Purpose To evaluate a group of very old patients who underwent emergent coronary angiography (CA). Methods We retrospectively analyzed a group of very old patients (≥90 year-old) who underwent emergent CA from January 2008 to September 2020. Clinical features were collected; survival and MACE were compared with an aged-matched control population with ACS not submitted to emergent CA. MACE was defined as a composite of all-cause death, ischemic stroke, ACS or hospitalization for acute heart failure. Results A total of 34 patients were enrolled: 56% female, with mean age 92±2 year-old. As for the cardiovascular risk factors, 88% had hypertension, 49% dyslipidaemia, 12% diabetes and 15% were previous smokers. Concerning other comorbidities, 27% had atrial fibrillation, 21% chronic kidney disease, 12% had cerebrovascular disease and median modified Rankin scale for neurologic disability was 2. Almost all patients had STE-ACS, 68% anterior and 29% inferior, inferolateral or inferoposterior infarction; 3% had infarction of indeterminate location. In CA, 65% had multivessel disease, 14% of them involving left main coronary artery; coronary intervention was performed in 71% of patients (mostly stent implantation), the remaining 29% had no invasive treatment. Concerning to clinical status, median troponin was 131 517 ng/L and median BNP 496 pg/mL; 36% of patients evolved in Killip class III or IV and only 32% of patients had normal left ventricular systolic function. Regarding mortality, 38% of patients died in the index-event versus 25% in the aged-matched control group (p=0.319). During five years of follow-up, there was no significant difference in mortality between the two groups (Log Rank, p=0.403) and more than 50% of patients died in two years. Comparing MACE occurrence, both groups were similar (Log Rank, p=0,662), with more than 80% having at least one event in five years. Conclusion Very old patients submitted to emergent CA had a high percentage of multivessel disease, left ventricular dysfunction and mortality during hospitalization. Compared to an aged-matched control group, they showed no survival or MACE benefit of emergent CA strategy during a five-years follow-up. Although this is a small study, these findings highlight the efforts that should be made to optimize care in this vulnerable population, under-represented in the clinical trials. Special caution should be given to avoid possible unnecessary discomfort in this setting. Funding Acknowledgement Type of funding sources: None. MACE analysis

Introduction Acute occlusion of the unprotected left main coronary artery (LMCA) is an uncommon occurrence associated with a dismal prognosis. Whereas the role of early recruited coronary collateral circulation (CC) in prognosis of ST-segment elevation acute myocardial infarction (STEMI) patients is still controversial, it seems to be important in patients with acute LMCA occlusion. This study aimed to evaluate the coronary CC in patients with acute LMCA occlusion and its impact in short and long-term outcomes. Methods In a retrospective two-center study, we identified 7630 patients with STEMI or high-risk non-ST segment elevation myocardial infarction who underwent emergent coronary angiography between January 2008 and December 2020. Among this cohort, we analyzed 83 patients who presented with unprotected LMCA acute occlusion (Thrombolysis In Myocardial Infarction – TIMI ≤2) and classified them in 2 groups based on the degree of CC through the right coronary artery as seen in the emergent angiography: patients with no filling of collateral vessels or filling of collateral vessels without any epicardial filling of the occluded vessel [Rentrop class 0–1 (71 patients)]; and patients with partial or complete epicardial filling by collateral vessels [CC Rentrop class 2–3 (12 patients)]. Results Compared to patients with CC Rentrop 0–1, patients with CC Rentrop 2–3 presented significantly later to medical attention (symptom to coronary angiography time 8.7 vs 4.3 hours, p=0.02). Despite that, patients with CC Rentrop 2–3 had a significantly lower prevalence of cardiogenic shock at admission (16.7 vs 57.7%, p=0.01). During hospitalization, Killip class III-IV presentation (33.3 vs 88.7%, p Conclusion A well-developed coronary CC was associated to lower short-term mortality in patients presenting with acute occlusion of the unprotected LMCA. Nevertheless, in patients surviving index-event, there was no difference in the long-term outcomes. Further studies are needed to clarify if clinical approach (eg. early short-term mechanical circulatory support) of patients with CC Rentrop 0–1 should be different from those with CC Rentrop 2–3 in order to improve the outcomes of the former patients. Funding Acknowledgement Type of funding sources: None.

Funding Acknowledgements Type of funding sources: None. Background Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease (MINOCA) is a clinical entity that occurs in up to 15% of all acute coronary syndromes (ACS). It is a "working diagnosis", as it is constituted by several etiologies. Purpose To identify the utility of CMR in determining the etiological diagnosis of MINOCA events, with potential impact in the therapeutic management of these patients. Methods Patients with MINOCA who were admitted to the Cardiology department at a tertiary center, between 2015 and 2020, were included. MINOCA was defined as an ACS with non-obstructive ( Results In a population of 29 patients, the mean age was 55 ± 17 years-old at the time of the cardiac event, 51.7% were male. Concerning to cardiovascular risk factors, 58.6% of patients had dyslipidaemia, 51.7% had hypertension, 13.7% were diabetic, 41.4% were smokers or previous smokers and 31.0% had obesity. Atrial fibrillation was present in 3.4% of patients. As for the EKG patterns, 41.4% of the patients had ventricular repolarization changes, 13.8% had a transitory ST elevation pattern, 6.9% had a complete left bundle branch block and 37.9% had a normal EKG; most of the ischemic EKG alterations were on the anterior wall (66.7%). The median high sensitivity I troponin levels were 1877.5 (IQR 225.3 – 5985.8) ng/L. The majority of patients (58.6%) had echocardiographic wall motion abnormalities; of those, the most common (41.1%) were on the left anterior descendent artery territory. CMR (performed at a median of 5 days from presentation) was able to identify the cause for the troponin rise in 58.6% of the cases; late gadolinium enhancement and oedema were present in 41.4% and 62.1% of patients, respectively. The mean left ventricle ejection fraction (EF) was 57.7 ± 8.5% and the mean right ventricle EF was 61.5 ± 6.1%. An ischemic pattern was present in 29.4% of the total population. In 17.6% of the patients findings were consistent with Takotsubo syndrome and in 29.4% with myocarditis. Conclusion CMR established the etiological cause in 58.6% of the cases, with potential implications in medical therapy. These findings highlight the importance of CMR in MINOCA diagnosis and the potential improvement in patient care with multi-modality imaging.

Introduction: Chronic kidney disease (CKD) is an independent risk factor for several unfavorable outcomes including cardiovascular disease (CVD), particularly in the elderly, who represent the most rapidly growing segment of the end-stage kidney disease (ESKD) population. Portugal has the highest European unadjusted incidence and prevalence rates of ESKD. In 2012, we started to follow a cohort of elderly CKD patients, we describe their baseline characteristics, risk profile, and cardiovascular disease burden. Methods: All CKD patients aged 65 years and older referred to our department during 2012 were enrolled. Baseline data included: demographic, CKD stage, medication, comorbid conditions. Estimated glomerular filtration rate (eGFR) was calculated by the CKD-EPI formula. Results: A total of 416 patients, 50% referred by primary care physicians, aged 77 ± 7 years, 52% male, with a median eGFR of 32 mL/min/1.73m2 participated in the study. Fifty percent had diabetes (DM), 85% dyslipidemia, 96% hypertension; 26% were current/former smokers, and 24% had a body mass index > 30 kg/m2. The prevalence of CVD was 62% and higher in stage 4-5 patients; in diabetics, it gradually increased with CKD progression (stage 3a < stage 3b < stage 4-5) (39, 58, 82%; p < 0.001). Conclusions: At baseline, our CKD elderly cohort had a higher burden of CVD. The prevalence of CVD was greater than in other European CKD cohorts. Lower level of eGFR was associated with a greater burden of CVD and was more pronounced in diabetics, highlighting the importance of strategically targeting cardiovascular risk reduction in these patients. Introdução: Doença renal crônica (DRC) é fator de risco independente para vários desfechos desfavoráveis, incluindo doença cardiovascular (DCV), particularmente em idosos, o segmento de crescimento mais rápido da população com doença renal terminal (DRT). Portugal tem a maior incidência europeia não-ajustada e a maior prevalência de DRT. Neste artigo caracterizamos uma coorte de idosos com DRC, referenciados para a nefrologia, com particular ênfase para o risco e carga de doença cardiovascular. Métodos: Foram incluídos todos os pacientes com DRC com 65 anos ou mais encaminhados ao nosso departamento em 2012. Os dados basais incluíram: demografia, estágio da DRC, medicação e comorbidades. A taxa de filtração glomerular (TFGe) foi calculada pela fórmula CKD-EPI. Resultados: Metade dos 416 pacientes incluídos foram encaminhados por médicos da atenção primária; sua idade era 77 ± 7 anos; 52% eram homens; a TFGe mediana era de 32 mL /min/1,73 m2. Metade tinha diabetes (DM), 85% dislipidemia, 96% hipertensão; 26% eram fumantes atuais/ antigos; 24% tinham índice de massa corporal > 30 kg/m2. A prevalência de DCV foi de 62%, sendo maior entre pacientes nos estágios 4-5; em diabéticos, aumentou gradualmente com a progressão da DRC (estágio 3a < estágio 3b < estágio 4-5) (39%, 58%, 82%; p < 0,001). Conclusões: A coorte de idosos com DRC apresentava inicialmente maior carga de DCV. A prevalência de DCV foi maior que em outras coortes europeias com DRC. Níveis menores de TFGe foram associados a carga maior de DCV e foram mais pronunciados entre diabéticos, destacando a importância de objetivar estrategicamente a redução do risco cardiovascular nesses pacientes. info:eu-repo/semantics/publishedVersion

Background and Aims With the geriatric population increasing, the patients reaching stage 5 chronic kidney disease (CKD) are older, frailer and have multiple comorbidities. Technological advances in renal replacement therapy (RRT) and easier access to dialysis resulted in an expansion on geriatric dialysis population. Conservative management (CM) is an option that should be considered in this population, where is crucial to balance the survival and quality of life. Beside mortality, with this study we aim to evaluated patient-outcomes (hospitalization, falls and functional capacity) in older and frailer stage 5 CKD patients receiving hemodialysis (HD) and in CM. Method We conducted a single center retrospective study in older (≥ 75years), frailer (Clinical Frailty Scale – CFS ≥ 5) and with multiple comorbidities (modified Charlson comorbidity index – mCCI ≥ 5 and) stage 5 CKD patients, admitted in our Nephrology department between January 1, 2014 to December 31, 2020. The eGFR was calculated through Chronic Kidney Disease Epidemiology Collaboration formula (CKD-EPI) at the time of decision or at the time of starting HD. The comorbidities were stratified using the mCCI and frailty was assessed with CFS at the time of decision in CM group (CMG) and at the start of HD (HDG). We evaluated hospitalizations, falls, CFS one-year later and survival in each group. Survival analysis was performed using the Kaplan–Meier method and was calculated at the beginning of RRT or eGFR ≤ 15ml/min/1.73m2 in CMG. Differences between the two groups were tested with Mann-Whitney U method. Results A total of 76 patients with indication to start RRT were included: 61.8% (n=47) initiated HD and 38.2% (n=29) were in CM. The reasons for CM decision were deterioration of clinical condition (n=11), expected survival less than 6 months (n=8), patient option (n=5) and cognitive impairment (n=5). Clinical characteristics are presented in Table 1. The CMG was older [median, IQR: 88 (85.5-90.5) vs 80 (77.0 – 83.0), p < 0.001] and had a lower BMI [23.44 (21.08 - 25.08) vs 26.23 (23.26 – 29.20), p=0.006]. Both groups did not differ significantly in terms of sex, CKD etiology, comorbidity or frailty. A total of 66 patients died at the end of the study [CMG 100% (n= 29) vs 78.7% HDG (n=37)]. The overall survival has higher on the HDG compared to the CMG with a median survival rate of 503 days (Fig 1). One-year survival rate was 53.5% in HDG vs 24% CMG (p Conclusion In our study, hemodialysis was associated to improved survival in older and frailer stage 5 CKD patients compared to CM. However, this group had more hospitalizations, falls and poor functional status. These outcomes have a crucial impact on quality of life in this population and should be consider at the time of treatment decision. One of the limitations of our study was small sample size in both groups. In the future, we consider that is important to perform multicenter studies focused on patients-outcomes. We also think that it’s important to understand the patient and family perspective in terms of quality of life and symptom burden associated to each treatment option.

Funding Acknowledgements Type of funding sources: None. Lipid control is one of the most important secondary cardiovascular prevention targets. The 4S trialin 1994 was the first study to demonstrate the benefit of statin therapy in coronary artery disease patients. More recently, the FOURIER trial (2017) and the ODYSSEY Outcomes (2018) demonstrated the cardiovascular benefit of adding a PCSK9 inhibitor to optimized antidyslipidemic therapy. Owing to the growing number of evidence showing the importance of aggressive lipid control, the European Society of Cardiology (ESC) 2019 Dyslipidemia Guidelines changed the recommendation of LDL targets from below 70 mg/dL to below 55 mg/dL in very high risk patients. In the light of this new recommendation, we retrospectively analysed all patients who participated in a Coronary Rehabilitation Program (CRP) after an Acute Coronary Syndrome at a tertiary center from May 2008 to June 2019. The CRP consisted in a multi-disciplinary approach to these patients, including 8 to 12 weekly sessions of phase II rehabilitation, exercise prescription, nutrition counselling and life-style intervention, with Cardiology follow-up at the end of the CRP (3 months), 6 months and 12 months after the event. Lipid profile was requested at baseline, 3 months and 12 months after the event. Dyslipidemia was defined using the ESC Guidelines definition. In total, 989 patients were enrolled: the mean age was 54 ± 10 years and 15% were female. Concerning to cardiovascular risk factors, 56.7% of patients had dyslipidaemia, 41.5% had hypertension, 18.1% were diabetic, 73.1% were smokers or previous smokers, 26.0% had family history of coronary disease and 14.0% had previous coronary disease. At hospital admission, mean LDL concentration was 121,7 ± 38,8 mg/dL with 2,9% of the patients with values below 55 mg/dL and 7,6% below 70 mg/dL. The vast majority of patients were medicated with statin at hospital discharge and maintained the prescription during the follow-up (97.5% and 97.1%, respectively). At the end of the CRP, there was a significant decrease of LDL values (p In conclusion, our real-life observational cohort showed that guideline recommended LDL target is not achieved in most of very high-risk patients even in a structured coronary rehabilitation program. Of note, the number of patients at LDL-target decreased from 3 months to 1-year follow-up. This state the importance of a sustained healthy lifestyle and therapy adherence, with aggressive pharmacologic therapy.

Duchamp caused a revolution in the art of the twentieth century with the readymade concept, and simultaneously he opened Pandora's Box, which converted art into a simulation and made it dependent on discursive practices. This degenerated into a deconstructive vulgate when, from the 1960s onwards, an ‘aesthetic of banality’ was accentuated and the media institutionalized the ‘guerrilla’ between the practices and the discourses. Art ‘wrecked’ in a regime of hyper-reality of the image, and the art paradigms and criteria shifted from aesthetics to the law of the financial markets. At the same time, the proliferation of coexisting cultural ideas and a revolving cultural miscegenation ended up splitting the kingdom of the art. In the art world today, there is a cleavage between artists: on one side, the adepts to the heteronomy (a line that was born with ready-made products), those who, following dominant rules, work for the market and the organizations; on the other side, those, more passionate, for whom art is a hermeneutics for self-knowledge. Meanwhile, Picasso's aura returns to the art scene, in a panorama that until now was adverse to him.