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Background Renal replacement therapy (RRT) is essential in the presence of life-threatening complications associated with acute kidney injury (AKI). In the absence of urgent indications, the optimal timing for RRT initiation is still under debate. This meta-analysis aims to compare the benefits between early and late RRT initiation strategies in critically ill patients with AKI. Methods Studies were obtained from three databases [Medical Literature Analysis and Retrieval System Online (MEDLINE), Cochrane Central Register of Controlled Trials (CENTRAL) and Scopus], searched from inception to May 2021. The selected primary outcome was 28-day mortality. Secondary outcomes included overall mortality, recovery of renal function (RRF) and RRT-associated adverse events. A random-effects model was used for summary measures. Heterogeneity was assessed through Cochrane I2 test statistics. Potential sources of heterogeneity for the primary outcome were sought using sensitivity analyses. Further subgroup analyses were conducted based on RRT modality and study population. Results A total of 13 randomized controlled trials including 5193 participants were analysed. No significant differences were found between early and late RRT initiation regarding 28-day mortality [risk ratio (RR) 1.00; 95% confidence interval (CI) 0.89–1.12, I² = 30%], overall mortality (RR 1.00; 95% CI 0.90–1.12, I² = 42%) and RRF (RR 1.02; 95% CI 0.92–1.13, I² = 53%). However, early RRT initiation was associated with a significantly higher incidence of hypotensive (RR 1.34; 95% CI 1.17–1.53, I² = 6%) and infectious events (RR 1.83; 95% CI 1.11–3.02, I² = 0%). Conclusions Early RRT initiation does not improve the 28-day and overall mortality, nor the likelihood of RRF, and increases the risk for RRT-associated adverse events, namely hypotension and infection.

Mestrado Bolonha em Gestão de Recursos Humanos Ao longo dos anos muito se tem falado e discutido, de acordo com diferentes autores, sobre os temas da liderança e da inteligência emocional (IE), e, de que forma a inteligência emocional pode ter um papel relevante na relação com entre líderes e liderados. No entanto, apesar do número de estudos existentes nesta área, ainda não existem estudos que esclareçam como pode o nível de inteligência emocional estar relacionado com estas duas variáveis. Assim, o objetivo deste estudo foi perceber em que medida o nível de inteligência emocional dos liderados impacta a relação com o líder, e, como pode o nível de inteligência dos líderes impactar o estilo de liderança transformacional através de um estudo quantitativo que permite perceber como líderes e liderados percecionam este nível. Os resultados obtidos explicam que existe uma correlação positiva e moderada entre o nível de inteligência emocional dos liderados e a relação entre o líder, e que, não existe correlação entre o nível de inteligência emocional dos líderes e o seu estilo de liderança transformacional. Em suma, os resultados obtidos apontam para a existência de uma relação entre o nível de inteligência emocional e as variáveis da liderança e da relação com o líder, contudo, existe a necessidade de mais investigação nesta área. Over the years, much has been said and discussed, according to different authors, on the topics of leadership and emotional intelligence (EI), and how emotional intelligence can play a relevant role in the relationship between leaders and followers. However, despite the number of existing studies in this area, there are still no studies that clarify how the level of emotional intelligence can be related to these two variables. Thus, the objective of this study was to understand to what extent the level of emotional intelligence of the subordinates impacts the relationship with the leader, and how can the level of intelligence of the leaders impact the transformational leadership style through a quantitative study that allows to understand how leaders and followers perceive this level. The results obtained explain that there is a positive and moderate correlation between the level of emotional intelligence of the followers and the relationship between the leader, and that there is no correlation between the level of emotional intelligence of the leaders and their transformational leadership style. In short, the results obtained point to the existence of a relationship between the level of emotional intelligence and the variables of leadership and the relationship with the leader, however, there is a need for further investigation in this area. info:eu-repo/semantics/publishedVersion

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

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.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.360 patients were included and 54.4% were male. Mean age was 74.9±12.2 years, serum creatinine was 1.97±0.84mg/dL, eGFR was 33.4±12.13ml/min/1.73mWe have independently externally validated the 2-year KFRE and shown that it has excellent discrimination. The KFRE should be incorporated in clinical care of patients with CKD to improve patient-clinician dialogue and provide guidance on timing of referral for nephrology evaluation and planning for dialysis access.

Background: In glomerular disease, the degree of proteinuria is closely related to the progression of chronic kidney disease, and its reduction is associated with a slower decline in the glomerular filtration rate (eGFR) and consequent improvement in the renal prognosis. The aim of this study was to evaluate the impact of proteinuria reduction on the decline of the eGFR in patients with glomerular disease, during the first year after the diagnosis. Methods: This was a retrospective analysis of patients with primary glomerular disease, followed at the Nephrology Department of Centro Hospitalar Universitário Lisboa Norte, during 2019. We analyzed demographic, clinical and laboratorial characteristics (creatinine, GFR, urine analysis and quantification of proteinuria determined by the proteinuria/creatinuria ratio, in the first morning urine or a 24 h urine sample). The outcome assessed was the decline in renal function, defined as a reduction in the GFR ≥ 25%, during the follow-up period. Results: We analyzed 197 patients with glomerular disease, with a mean age of 41.7 ± 19.7 years and follow-up time of 6.5 ± 5.3 years. At the time of the diagnosis, the eGFR was 81.5 ± 49.8 mL/min/1.73 m2 and proteinuria was 3.5 g/24 h (IQR 5.8). At one-year follow-up, median proteinuria was 0.9 g/24 h (IQR 2.4). At the end of the follow-up, mean eGFR was 72.1 ± 43.3 mL/min/1.73 m2. Proteinuria (p = 0.435) and the eGFR (p = 0.880) at the time of diagnosis did not correlate with long-term decline in the eGFR. Proteinuria < 1 g/24 h (HR 0.45 (95% CI 0.25–0.83) p = 0.011) after the first year was protective against long-term decline in the eGFR. It maintained this association with the long-term eGFR decline, independently of the duration of the follow-up (HR 0.30 (95% CI 0.17–0.52) p < 0.001). Conclusions: Proteinuria reduction to lower than 1 g/24 h, during the first year after diagnosis, was a protective factor for the long-term decline of kidney function, having a more important role than proteinuria or the GFR at the time of the diagnosis.

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.

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.

Antineutrophil cytoplasmic antibodies-associated vasculitis (AAV) is characterized by systemic inflammation and is the most common cause of new-onset glomerulonephritis in adults older than 50 years. Renal disease secondary to AAV can lead to chronic kidney disease (CKD) requiring renal replacement therapy in approximately 20–25% of patients. Relapses are infrequent in the population on dialysis, and treatment guidelines do not specify these patients. Reports regarding the clinical course, survival, or relapse rate after beginning dialysis are scarce. The authors present 3 cases of CKD patients on hemodialysis who presented with AAV relapse, successfully treated with rituximab, and provide a literature review on relapse treatment.

BACKGROUND AND AIMS The prevalence of chronic kidney disease (CKD) is growing worldwide and ranges from 8% to 16%. Mortality rates are higher in the first few months of haemodialysis (HD). Protein-energy malnutrition has been demonstrated to be a major risk factor for mortality in this population. The C-Reactive Protein to Albumin ratio (CAR) has been associated with increased mortality risk. We aimed to evaluate if CAR could be used to predict 6-month mortality in incident HD patients. METHOD Retrospective analysis of CKD patients who initiated chronic HD between January of 2014 and December of 2019 in a tertiary-care hospital in Portugal. CAR was calculated at HD start. We analyzed 6-month mortality. Variables were submitted to univariate and multivariate analysis to determine factors predictive of 6-month mortality after HD start. We assessed the logistic regression method of the CAR to predict 6-month mortality and the discriminatory ability 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 [76.50 ± 11.39 versus 67.29 ± 15.52 years; P 0.5, with an odds ratio of 5.362 (95% CI 3.208–8.963; P CONCLUSION In our study, we demonstrated that higher CAR was independently associated with a higher mortality rate in the first 6 months of starting HD, highlighting the prognostic importance of malnutrition and inflammation in patients starting chronic HD.

BACKGROUND AND AIMS 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 that has been extensively validated in multiple cohorts. The aim of this study was to validate this risk score in a Portuguese cohort. METHOD 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 four-variable Kidney Failure Risk Equation (KFRE) calibrated for a non-North American population was calculated. Requirement for 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 A total of 360 patients were included, and 54.4% were male. The 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. The mean calculated risk score was 6.2 ± 11.2%. A total of 23 patients required KRT (6.4%) in the 2-year follow-up. The hazard ratio was 1.1 [95% confidence interval (95% CI) 1.06–1.12; P < .001] for the 2-year risk of KRT. The KFRE predicted progression to KRT requirement with an auROC of 0.903, (95% CI 0.86–0.95; P 4.5% for 2-year nephrologist referral, with a hazard ratio of HR 26.7 [95% CI 6.15–116.3; P < .001] for 2-year risk of KRT. requirement. CONCLUSION We have independently externally validated the 2-year KFRE and shown that it has excellent discrimination. The KFRE should be incorporated into the clinical care of patients with CKD to improve patient-clinician dialogue and provide guidance on the timing of referral for nephrology evaluation and planning for dialysis access.

BACKGROUND AND AIMS Chronic kidney disease (CKD) is a significant cause of morbidity, cardiovascular and all-cause mortality. CHA2DS2VASc is a score system used in patients with atrial fibrillation to predict thromboembolic risk. However, it also appears to be useful to predict mortality risk. The aim of the study was to evaluate the CHA2D2SVASc score as a tool to predict 1-year mortality after starting haemodialysis and identify factors associated with higher mortality. METHOD Retrospective analysis of patients who started haemodialysis between January of 2014 and December of 2019 at Centro Hospitalar Universitário Lisboa Norte. We evaluated mortality within 1 year of starting haemodialysis. The CHA2D2SVASc score was calculated at the start of haemodialysis. Variables were submitted to univariate and multivariate analysis to determine factors predictive of 1-year mortality after HD start. We assessed the logistic regression method of the CHA2DS2VASc to predict 1-year mortality and the discriminatory ability was determined using the receiver operating characteristic curve. RESULTS Of 856 patients analyzed, the mean age was 68.3 ± 15.5 years, the majority were male (61.1%) and Caucasian (84.5%). Mortality within 1 year after haemodialysis started was 17.8% (n = 152). The CHA2D2SVASc score was significantly higher (4.4 ± 1.7 versus 3.5 ± 1.8; P < .001) in patients who died and accurately predicted the 1-year risk of mortality {AUC: 0.646, [95% confidence interval (95% CI) 0.6–0.7]; P < .001}, with a sensitivity 71.7% and specificity of 49.1%, a positive predictive value of 23.9% and a negative predictive value of 89.2%. In the multivariate analysis, CHA2D2SVASc ≥3.5 (adjusted OR: 2.24, 95% CI 1.48–3.37; P < .001] and central venous catheter at dialysis start (adjusted HR: 3.06, 95% CI 1.93–4.85) were significant predictors of 1-year mortality. CONCLUSION CHA2D2SVASc score ≥ 3.5 and central venous catheter at haemodialysis start were predictors of 1-year mortality, allowing for risk stratification in haemodialysis patients.

BACKGROUND AND AIMS Percutaneous renal biopsy is a fundamental technique for the diagnosis of numerous renal pathologies. However, it is an invasive technique that requires operator experience and is associated with adverse outcomes. Bleeding complications such as haematuria or perirenal hematoma are frequent, but generally self-limiting, and may rarely be severe to the point of culminating in hypovolemic shock or death. The objectives of this study are to identify the rate of adverse outcomes and potential predictors of adverse outcomes related to the procedure. METHOD A retrospective analysis of patients undergoing native kidney biopsy at a tertiary centre, between 2015 and 2019 was carried out, based on the demographic and clinical characteristics of the population, analyses (creatinine at admission, pre-procedure and post-procedure blood counts) and control at 24 h after biopsy) and imaging methods (renal ultrasound 24 h after biopsy). RESULTS A total of 176 patients were selected, with a mean age of 48.1 ± 17.6 years. They were mostly caucasian (80.1%) and there was a predominance of females (55.7%). Approximately 46.6% had arterial hypertension, although all had their blood pressure controlled at the time of the biopsy. Mean pre-biopsy creatinine value was 2.0 ± 1.7 mg/dL. Mean pre-biopsy haemoglobin value was 12.1 ± 2.0 g/dL and 24 h post-biopsy 11.8 ± 2 .0 g/dL. There was an overall complication rate of 30.1%, corresponding to 5 cases of haematuria, 36 minor hematomas and 8 major hematomas. There were no deaths and there was no need for surgical intervention to control the bleeding. The only predictor of post-biopsy complications was age, with younger patients having fewer complications (43.9 ± 16.2 versus 50.0 ± 17.9, P = .036). There was no correlation between pre-biopsy creatinine or haemoglobin values and the occurrence of complications, nor was there a greater number of complications in hypertensive patients. CONCLUSION Although bleeding complications were relatively frequent in this sample, serious events were rare, as this reinforces the safety of this procedure (which provides valuable information about the prognosis and decision of the therapy to be instituted). The presence of arterial hypertension and the pre-biopsy creatininemia value did not increase the risk of complications related to the procedure.

BACKGROUND AND AIMS Renal replacement therapy (RRT) is consensual in the presence of life-threatening complications associated with acute kidney injury (AKI). In the absence of urgent indications, the optimal timing for RRT initiation is still under debate. This systematic review with meta-analysis aims to compare the benefits between early and late RRT initiation strategies in critically ill patients with AKI. METHOD Studies were obtained from three databases (MEDLINE, CENTRAL and SCOPUS), searched from inception to May 2021. The selected primary outcome was 28-day mortality. Secondary outcomes included overall mortality, recovery of renal function (RRF) and RRT-associated adverse events. A random-effects model was used for summary measures. Heterogeneity was assessed through Cochrane I2 test statistics. Potential sources of heterogeneity for the primary outcome were sought using sensitivity analyses. Further subgroup analyses were conducted based on the RRT modality. RESULTS A total of 13 randomized controlled trials, including 5193 participants, were analyzed. No significant differences were found between early and late RRT initiation regarding 28-day mortality [risk ratio (RR) 1.00, 95% confidence interval (95% CI) 0.89–1.12; I² = 30%], overall mortality (RR 1.00, 95% CI 0.90–1.12; I² = 42%) and RRF (RR 1.02, 95% CI 0.92–1.13; I² = 53%). However, early RRT initiation was associated with a significantly higher incidence of hypotensive (RR 1.34, 95% CI 1.17–1.53; I² = 6%) and infectious events (RR 1.83, 95% CI 1.11–3.02; I² = 0%). CONCLUSION Early RRT initiation does not improve the 28-day or overall mortality, nor the likelihood of RRF and increases the risk for RRT-associated adverse events, namely hypotension and infection.

Right atrial thrombus is commonly associated to catheters. Catheter-related right atrial thrombus (CRAT) in hemodialysis patients frequently presents as pulmonary embolism. Although CRAT is sometimes asymptomatic, even in these cases it is associated with worse prognosis. The management strategy for CRAT is not well established, however, along with catheter removal, anticoagulation, thrombolysis, and surgical thrombectomy may be performed. Suspicion of asymptomatic pulmonary embolism associated to CRAT is important in order to perform proper treatment. The authors of this article report two cases of asymptomatic pulmonary thromboembolism due to CRAT in hemodialysis patients and perform a review of the literature.

Atypical hemolytic uremic syndrome (aHUS) is a rare disease. It results from the dysregulation of the alternative complement pathway on the cell surface which causes endothelial damage. Increasing evidence links, these abnormalities to mutations in genes of complement regulators or with autoantibodies against complement factors. These mutations have an incomplete penetrance and variable phenotype. Cytomegalovirus (CMV) is endemic throughout the world, and the incidence of severe CMV disease in immunocompetent adults appears to be greater than previously thought. aHUS and nephrotic syndromes associated with CMV infection are rare. Identification of triggers for aHUS manifestation in a genetically susceptible patient is extremely important since this permits a faster initiation of treatment and clinical improvement. We report a case of a man with a homozygotic deletion of CFHR3-1 whose initial presentation was aHUS and nephrotic syndromes associated with CMV infection.

The incidence of acute kidney injury (AKI) has increased in the past decades. AKI complicates up to 15% of hospitalizations and can reach up to 50–60% in critically ill patients. Besides the short-term impact of AKI in patient outcomes, several studies report the association between AKI and adverse long-term outcomes, such as recurrent AKI episodes in 25–30% of cases, hospital re-admissions in up to 40% of patients, an increased risk of cardiovascular events, an increased risk of progression of chronic kidney disease (CKD) after AKI and a significantly increased long-term mortality. Despite the long-term impact of AKI, there are neither established guidelines on the follow-up care of AKI patients, nor treatment strategies to reduce the incidence of sequelae after AKI. Only a minority of patients have been referred to nephrology post-discharge care, despite the evidence of improved outcomes associated with nephrology referral by addressing cardiovascular risk and risk of progression to CKD. Indeed, AKI survivors should have specialized nephrology follow-up to assess kidney function after AKI, perform medication reconciliation, educate patients on nephrotoxic avoidance and implement strategies to prevent CKD progression. The authors provide a comprehensive review of the transition from AKI to CKD, analyse the current evidence on the long-term outcomes of AKI and describe predisposing risk factors, highlight the importance of follow-up care in these patients and describe the current therapeutic strategies which are being investigated on their impact in improving patient outcomes.

Background Acute kidney injury (AKI) is frequent during hospitalization and may contribute to adverse short- and long-term consequences. Acute kidney disease (AKD) reflects the continuing pathological processes and adverse events developing after AKI. We aimed to evaluate the association of AKD, long-term adverse renal function and mortality in a cohort of patients with sepsis. Methods We performed a retrospective analysis of adult patients with septic AKI admitted to the Division of Intensive Medicine of the Centro Hospitalar Lisboa Norte (Lisbon, Portugal) between January 2008 and December 2014. Patients were categorized according to the development of AKI using the Kidney Disease: Improving Global Outcomes (KDIGO) classification. AKI was defined as an increase in absolute serum creatinine (SCr) ≥0.3 mg/dL or by a percentage increase in SCr ≥50% and/or by a decrease in urine output to 6 h. AKD was defined as presenting at least KDIGO Stage 1 criteria for >7 days after an AKI initiating event. Adverse renal outcomes (need for long-term dialysis and/or a 25% decrease in estimated glomerular filtration rate after hospital discharge) and mortality after discharge were evaluated. Results From 256 selected patients with septic AKI, 53.9% developed AKD. The 30-day mortality rate was 24.5% (n = 55). The mean long-term follow-up was 45.9 ± 43.3 months. The majority of patients experience an adverse renal outcome [n = 158 (61.7%)] and 44.1% (n = 113) of patients died during follow-up. Adverse renal outcomes, 30-day mortality and long-term mortality after hospital discharge were more frequent among AKD patients [77.5 versus 43.2% (P Conclusions AKD after septic AKI was independently associated with the risk of long-term need for dialysis and/or renal function decline and with the risk of death after hospital discharge.

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.

To determine risk factors for in-hospital mortality in elderly patients with acute kidney injury (AKI) requiring dialysis. AKI requiring dialysis is frequent in elderly and is associated with an increased intra-hospital mortality. With the growing number of older individuals among hospitalized patients with AKI demands a thorough investigation of the factors that contribute to their mortality to improve outcomes. We performed a retrospective analysis of patients older than 80 years, admitted due to AKI requiring dialysis between January 2016 and December 2017. Patients who need intensive-care units (ICU) admission were excluded. The primary outcome was all-cause in-hospital mortality. A total of 154 patients were evaluated. The mean age was 85.3 ± 4.0 years and 76 patients (49.4%) were male. The overall mortality rate was 26.6%. On the multivariate analysis, serum albumin (OR 0.42 [95% CI 0.21–0.85], p 0.016), C reactive protein/albumin ratio (OR 1.04 [95% CI 0.99–1.09], and renal function recovery (OR 018 [95% CI 0.49–0.65], p 0.009) were the factors associated with higher in-hospital mortality. Lower albumin level, higher C reactive protein/albumin ratio at admission, and absence of renal function recovery are associated with increased in-hospital mortality’s risk in elderly with acute kidney injury requiring dialysis.

A considerable number of patients present with stuck CVC after long-use of CVC, which is thought to result from the adhesion of the fibrous sheath, formed over the CVC, to the vessel or atrial wall. The removal of these catheters is a difficult and risky procedure. Hong reported a minimally invasive technique through endoluminal balloon dilation, which successfully breaks the adhesions and expands the vein, thus allowing for an easy removal of the CVC. The authors present two cases of a variant method of Hong’s technique, and provide a literature review on stuck catheters. Our experience is that balloon angioplasty dilation is a safe and practical option. We highlight the role of experienced interventional nephrologists or radiologists in the management of this complication as endovascular treatment is the first line treatment.

Background: CKD is a significant cause of morbidity, cardiovascular and all-cause mortality. CHA2DS2-VASc is a score used in patients with atrial fibrillation to predict thromboembolic risk; it also appears to be useful to predict mortality risk. The aim of the study was to evaluate CHA2DS2-VASc scores as a tool for predicting one-year mortality after hemodialysis is started and for identifying factors associated with higher mortality. Methods: Retrospective analysis of patients who started hemodialysis between January 2014 and December 2019 in Centro Hospitalar Universitário Lisboa Norte. We evaluated mortality within one year of hemodialysis initiation. The CHA2DS2-VASc score was calculated at the start of hemodialysis. Results: Of 856 patients analyzed, their mean age was 68.3 ± 15.5 years and the majority were male (61.1%) and Caucasian (84.5%). Mortality within one-year after starting hemodialysis was 17.8% (n = 152). The CHA2DS2-VASc score was significantly higher (4.4 ± 1.7 vs. 3.5 ± 1.8, p < 0.001) in patients who died and satisfactorily predicted the one-year risk of mortality (AUC 0.646, 95% CI 0.6–0.7, p < 0.001), with a sensitivity of 71.7%, a specificity of 49.1%, a positive predictive value of 23.9% and a negative predictive value of 89.2%. In the multivariate analysis, CHA2DS2-VASc ≥3.5 (adjusted HR 2.24 95% CI (1.48–3.37), p < 0.001) and central venous catheter at dialysis initiation (adjusted HR 3.06 95% CI (1.93–4.85)) were significant predictors of one-year mortality. Conclusion: A CHA2DS2-VASc score ≥3.5 and central venous catheter at hemodialysis initiation were predictors of one-year mortality, allowing for risk stratification in hemodialysis patients.

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. Resumo Introdução: O uso de Rituximab (RTX) em doenças glomerulares (DG) aumentou nos últimos anos, embora ainda utilizado apenas em uma pequena fração de pacientes. Métodos: Conduzimos em nosso centro, de 2010-2020, um estudo retrospectivo de único centro de pacientes adultos com nefropatia membranosa (NM), glomeruloesclerose segmentar focal (GESF), nefrite lúpica (NL) e vasculite tratada com RTX como terapia de primeira ou segunda linha. Resultados: Identificamos 19 pacientes; 36,8% tinham NM; 25,0% cada apresentava GESF, NL e vasculite. RTX foi terapia de primeira linha em 26,3% dos pacientes e em 73,7% foi terapia de segunda linha. O tempo médio de acompanhamento foi 7,7 ± 7,2 anos. Em NM, 2 pacientes (28,6%) tiveram remissão completa (RC), 2 pacientes (28,6%) remissão parcial (RP), e 3 pacientes (42,9%) não tiveram resposta (NR). Na GESF, 2 pacientes (50,0%) apresentaram RC, 1 paciente (25,0%) não teve resposta e, 1 paciente, deterioração renal. Dois pacientes (50,0%) apresentaram NL classe IV com RC após RTX, 1 paciente com NL classe IIIC/V não teve resposta, e 1 paciente com NL classe II apresentou deterioração renal. Na vasculite, 3 pacientes (75,0%) apresentaram RC e 1 paciente RP. Reações à infusão ocorreram em 2 pacientes (10,5%) e um paciente apresentou múltiplas complicações infecciosas. Conclusões: A eficácia do RTX em tratar diferentes tipos de DG imunomediada tem sido demonstrada com diferentes taxas de resposta, mas com perfil geral seguro. Em nossa série de casos, os resultados também são encorajadores. Estudos longitudinais são necessários para compreender melhor o efeito do RTX na DG.