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Lay summary Peritoneal dialysis (PD) uses the peritoneal membrane for dialysis. The peritoneal membrane is a thin layer of tissue that lines the abdomen. The lining is used as a filter to help remove extra fluid and poisonous waste from the blood. Everybody is unique. What is normal for one person’s membrane may be very different from another person’s. The kidney care team wants to provide each person with the best dialysis prescription for them and to do this they must evaluate the person’s peritoneal lining. Sometimes dialysis treatment itself can cause the membrane to change after some years. This means more assessments (evaluations) will be needed to determine whether the person’s peritoneal membrane has changed. Changes in the membrane may require changes to the dialysis prescription. This is needed to achieve the best dialysis outcomes. A key tool for these assessments is the peritoneal equilibration test (PET). It is a simple, standardized and reproducible tool. This tool is used to measure the peritoneal function soon after the start of dialysis. The goal is to understand how well the peritoneal membrane works at the start of dialysis. Later on in treatment, the PET helps to monitor changes in peritoneal function. If there are changes between assessments causing problems, the PET data may explain the cause of the dysfunction. This may be used to change the dialysis prescription to achieve the best outcomes. The most common problem with the peritoneal membrane occurs when fluid is not removed as well as it should be. This happens when toxins (poisons) in the blood cross the membrane more quickly than they should. This is referred to as a fast peritoneal solute transfer rate (PSTR). Since more efficient fluid removal is associated with better outcomes, developing a personal PD prescription based on the person’s PSTR is critically important. A less common problem happens when the membrane fails to work properly (also called membrane dysfunction) because the peritoneal membrane is less efficient, either at the start of treatment or developing after some years. If membrane dysfunction gets worse over time, then this is associated with progressive damage, scarring and thickening of the membrane. This problem can be identified through another change of the PET. It is called reduced ‘sodium dip’. Membrane dysfunction of this type is more difficult to treat and has many implications for the individual. If the damage is major, the person may need to stop PD. They would need to begin haemodialysis treatment (also spelled hemodialysis). This is a very important and emotional decision for individuals with kidney failure. Any decision that involves stopping PD therapy or transitioning to haemodialysis therapy should be made jointly between the clinical team, the person on dialysis and a caregiver, if requested. Although evidence is lacking about how often tests should be performed to determine peritoneal function, it seems reasonable to repeat them whenever there is difficulty in removing the amount of fluid necessary for maintaining the health and well-being of the individual. Whether routine evaluation of membrane function is associated with better outcomes has not been studied. Further research is needed to answer this important question as national policies in many parts of the world and the COVID-19 has placed a greater emphasis and new incentives encouraging the greater adoption of home dialysis therapies, especially PD. For Chinese and Spanish Translation of the Lay Summary, see Online Supplement Appendix 1. Key recommendations Guideline 1: A pathophysiological taxonomy: A pathophysiological classification of membrane dysfunction, which provides mechanistic links to functional characteristics, should be used when prescribing individualized dialysis or when planning modality transfer (e.g. to automated peritoneal dialysis (PD) or haemodialysis) in the context of shared and informed decision-making with the person on PD, taking individual circumstances and treatment goals into account. (practice point) Guideline 2a: Identification of fast peritoneal solute transfer rate (PSTR): It is recommended that the PSTR is determined from a 4-h peritoneal equilibration test (PET), using either 2.5%/2.27% or 4.25%/3.86% dextrose/glucose concentration and creatinine as the index solute. (practice point) This should be done early in the course dialysis treatment (between 6 weeks and 12 weeks) (GRADE 1A) and subsequently when clinically indicated. (practice point) Guideline 2b: Clinical implications and mitigation of fast solute transfer: A faster PSTR is associated with lower survival on PD. (GRADE 1A) This risk is in part due to the lower ultrafiltration (UF) and increased net fluid reabsorption that occurs when the PSTR is above the average value. The resulting lower net UF can be avoided by shortening glucose-based exchanges, using a polyglucose solution (icodextrin), and/or prescribing higher glucose concentrations. (GRADE 1A) Compared to glucose, use of icodextrin can translate into improved fluid status and fewer episodes of fluid overload. (GRADE 1A) Use of automated PD and icodextrin may mitigate the mortality risk associated with fast PSTR. (practice point) Guideline 3: Recognizing low UF capacity: This is easy to measure and a valuable screening test. Insufficient UF should be suspected when either (a) the net UF from a 4-h PET is Guideline 4a: Diagnosing intrinsic membrane dysfunction (manifesting as low osmotic conductance to glucose) as a cause of UF insufficiency: When insufficient UF is suspected, the 4-h PET should be supplemented by measurement of the sodium dip at 1 h using a 3.86% glucose/4.25% dextrose exchange for diagnostic purposes. A sodium dip ≤5 mmol/L and/or a sodium sieving ratio ≤0.03 at 1 h indicates UF insufficiency. (GRADE 2B) Guideline 4b: Clinical implications of intrinsic membrane dysfunction (de novo or acquired): in the absence of residual kidney function, this is likely to necessitate the use of hypertonic glucose exchanges and possible transfer to haemodialysis. Acquired membrane injury, especially in the context of prolonged time on treatment, should prompt discussions about the risk of encapsulating peritoneal sclerosis. (practice point) Guideline 5: Additional membrane function tests: measures of peritoneal protein loss, intraperitoneal pressure and more complex tests that estimate osmotic conductance and ‘lymphatic’ reabsorption are not recommended for routine clinical practice but remain valuable research methods. (practice point) Guideline 6: Socioeconomic considerations: When resource constraints prevent the use of routine tests, consideration of membrane function should still be part of the clinical management and may be inferred from the daily UF in response to the prescription. (practice point)

Background Optimal immunosuppressive treatment for membranous nephropathy is still a matter of controversy. Current recommendations include oral cyclophosphamide combined with steroids (modified Ponticelli regimen) as first-line treatment in patients who are high risk. However, concerns about the cumulative toxicity of oral cyclophosphamide persist. In the last 30 years, a protocol based on low-dose intravenous cyclophosphamide plus steroids has been used to treat membranous nephropathy in Uruguay. We aimed to assess the efficacy of this regimen to induce clinical remission in patients with membranous nephropathy. Methods In this retrospective, observational cohort study, we analyzed the outcome of 55 patients with membranous nephropathy treated between 1990 and 2017 with a 6-month course of alternating steroids (months 1, 3, and 5) plus intravenous cyclophosphamide (single dose of 15 mg/kg on the first day of months 2, 4, and 6). Results At 24 months, 39 (71%) patients achieved clinical response with complete remission observed in 23 patients (42%) and partial remission in 16 (29%). Median time to achieve partial and complete remission was 5.9 and 11.5 months, respectively. Absence of response was observed in 16 patients (29%), five of whom started chronic RRT after a median follow-up of 3.5 years. Clinical relapse occurred in nine of 33 (27%) patients at a median of 34 months after treatment discontinuation. Conclusions Replacement of oral cyclophosphamide with a single intravenous pulse on months 2, 4, and 6 of the modified Ponticelli regimen can be an effective and safe alternative for treatment of membranous nephropathy. Podcast This article contains a podcast at https://www.asn-online.org/media/podcast/K360/2020_09_24_KID0002802020.mp3

Resumen: La enfermedad renal crónica tiene una prevalencia estimada de 6,5% a 8% en los adultos mayores de 18 años en Uruguay. A pesar de los esfuerzos por realizar un diagnóstico temprano y retrasar su progresión un porcentaje de pacientes requiere terapia de reemplazo renal (TRR) mediante diálisis, con una tasa de incidencia anual de 166 pacientes/millón de población. A pesar de las mejoras en el cuidado nefrológico y en las técnicas de hemodiálisis, la mortalidad anual de los pacientes en esta técnica es elevada en nuestro país (16,5%) y en todo el mundo. Con el objetivo de mejorar estos aspectos se han ensayado técnicas dialíticas que asocian la convección como estrategia para depurar moléculas de mayor tamaño que habitualmente no se depuran en la hemodiálisis convencional. La hemodiafiltración en línea (HDF-OL) es una técnica convectiva. Cuando se utiliza como TRR crónica se asocia a una reducción de la mortalidad de 30%-35% comparada con la hemodiálisis convencional. En el año 2014 se instrumentó esta técnica en el Hospital de Clínicas, siendo el centro pionero en el país en contar con ella como TRR crónico. El proceso de implementación implicó cambios de la infraestructura (monitores de diálisis, centro de tratamiento del agua), formación de recursos humanos, cambios en el funcionamiento y controles microbiológicos programados. El control de calidad sistemático y los diferentes estudios realizados en este período de cinco años han mostrado que es una técnica segura, capaz de remover solutos de tamaño medio y de disminuir los requerimientos de eritropoyetina. No se encuentra aún financiada por el sistema de salud, lo que puede constituir una barrera en su difusión a nivel nacional. En el presente trabajo se revisan las características fundamentales de la hemodiafiltración, su beneficio comparado con la hemodiálisis convencional, y el proceso de implementación de la técnica junto con algunos resultados iniciales en el Hospital de Clínicas. Summary: Chronic kidney disease has an estimated prevalence of 6.5% to 8% in adults older than 18 years old in Uruguay. Despite efforts to make an early diagnosis and delay its progression, a percentage of patients require renal replacement therapy (RRT) with dialysis, the annual incidence rate being 166 patients per million population. Regardless of improvements in nephrology care and hemodialysis techniques, annual mortality ratex for this technique is high in our country (16.5%) and around the world. In order to improve these aspects, different dialysis techniques associating convection as a strategy to purify larger molecules that are rarely purified in conventional hemodialysis have been tried out. Online haemodiafiltration (OL-HDF) is a convective technique. When used as a chronic RRT it is associated to a 30-35% reduction in mortality compared to conventional hemodialysis. In 2014 this technique was introduced in the University Hospital, being it the first center that offered it as chronic renal replacement therapy. The implementation process implied changes in infrastructure (dialysis computer screens, water treatment center), the training of human resources, changes in the operation system and programmed microbiological controls. A systematic quality control and the different studies conducted in this 5-year period have proved it is a safe technique that removes average size solutes and reduces the erythropoietin requirements. This technique is still not funded by the health system, what may result in an obstacle for it to be applied nationally. This study reviews the main features of haemodiafiltration, its benefits when compared to conventional hemodialysis and the process needed to implement the technique, along with initial results in the University Hospital. Resumo: No Uruguai a doença renal crônica tem uma prevalência estimada de 6.5 a 8% nos adultos maiores de 18 anos. Apesar dos esforços para realizar um diagnóstico precoce e retardar sua progressão uma porcentagem de pacientes requer terapia de substituição da função renal (TSFR) mediante diálise, com uma taxa de incidência anual de 166 pacientes/milhão de habitantes. Independentemente das melhorias na atenção nefrológica e nas técnicas de hemodiálise, a mortalidade anual dos pacientes em tratamento com esta técnica é elevada no Uruguai (16.5%) e no mundo todo. Buscando melhorar esses aspectos foram ensaiadas varias técnicas dialíticas que associam a convecção como estratégia para depurar moléculas de maior tamanho que habitualmente não são depuradas na hemodiálise convencional. A hemodiafiltração on line (HDF-OL) é uma técnica convectiva. Quando é utilizada como TSFR crônica está associada a uma redução da mortalidade de 30-35% comparada com a hemodiálise convencional. Esta técnica foi instrumentada em 2014 no Hospital de Clínicas, sendo este o centro pioneiro no Uruguai em utilizá-la como TSFR crônico. O processo de implementação impôs mudanças na infraestrutura (monitores de diálise, centro de tratamento da água), formação de Recursos Humanos e mudanças no funcionamento e controles microbiológicos programados. O controle de qualidade sistemático e os diferentes estudos realizados neste período de 5 anos mostraram que é uma técnica segura, capaz de remover solutos de tamanho médio e de reduzir os requerimentos de eritropoietina. A atual falta de financiamento pelo sistema de saúde pode ser uma barreira para sua difusão no país. Neste trabalho faz-se uma revisão das características fundamentais da hemodiafiltração, seu beneficio comparado com a hemodiálise convencional, o processo de implementação da técnica e alguns resultados iniciais do Hospital de Clínicas.

Introduction The Renal Healthcare Program Uruguay (NRHP-UY) is a national, multidisciplinary program that provides care to chronic kidney disease (CKD) patients. In this study, we report the global results of CKD patient outcomes and a comparison between those treated at the NRHP-UY Units, with those patients who were initially included in the program but did not adhere to follow up. Methods A cohort of not-on dialysis CKD patients included prospectively in the NRHP-UY between October 1st 2004 and September 30th 2017 was followed-up until September 30th 2019. Two groups were compared: a) Nephrocare Group: Patients who had at least one clinic visit during the first year on NRHP-UY (n = 11174) and b) Non-adherent Group: Patients who were informed and accepted to be included but had no subsequent data registered after admission (n = 3485). The study was approved by the Ethics Committee and all patients signed an informed consent. Outcomes were studied with Logistic and Cox´s regression analysis, Fine and Gray competitive risk and propensity-score matching tests. Results 14659 patients were analyzed, median age 70 (60–77) years, 56.9% male. The Nephrocare Group showed improved achievement of therapeutic goals, ESKD was more frequent (HR 2.081, CI 95%1.722–2.514) as planned kidney replacement therapy (KRT) start (OR 2.494, CI95% 1.591–3.910), but mortality and the combined event (death and ESKD) were less frequent (HR 0.671, CI95% 0.628–0.717 and 0.777, CI95% 0.731–0.827) (p = 0.000) compared to the Non-adherent group. Results were similar in the propensity-matched group: ESKD (HR 2.041, CI95% 1.643–2.534); planned kidney replacement therapy (KRT) start (OR 2.191, CI95% 1.322–3.631) death (HR 0.692, CI95% 0.637–0.753); combined event (HR 0.801, CI95% 0.742–0.865) (p = 0.000). Conclusion Multidisciplinary care within the NRHP-UY is associated with timely initiation of KRT and lower mortality in single outcomes, combined analysis, and propensity-matched analysis.

– Los pacientes con enfermedad renal en todas sus etapas (ERC etapas 1-5, diálisis, trasplante renal) deben ser una población prioritaria en el plan de vacunación contra SARS-CoV-2. – En todos los casos, la vacunación debe administrarse sin importar si los pacientes tuvieron antes COVID-19 o si tienen títulos de IgG positivos para SARS-CoV-2. – Debe vacunarse a todos los pacientes con ERC avanzada, con o sin diálisis crónica, con los esquemas habituales propuestos para las diferentes vacunas disponibles en el medio. – Debe vacunarse a todos los pacientes en lista de espera de trasplante renal. En quienes se encuentran programdos para trasplante inter vivos es deseable que completen la vacunación un mes antes del procedimiento. – Hay que vacunar a todos los pacientes receptores de trasplante renal luego del primer mes del trasplante y aprovechar las situaciones clínicas de estabilidad y menor requerimiento de inmunosupresión. En las situaciones en que se administra timoglobulina o rituximab al trasplante se recomienda diferir la vacunación hasta el tercer mes. Cuando se indica tratamiento contra el rechazo (bolos de metilprednisolona, recambio plasmático terapéutico, gammaglobulina), se recomienda posponer la vacunación al menos dos semanas. – Es preciso vacunar a los pacientes con enfermedades autoinmunitarias (enfermedades autoinmunitarias sistémicas, glomerulopatías), con o sin tratamiento inmunosupresor, de preferencia en el momento en que la enfermedad subyacente esté estable y en el mejor momento de la inmunosupresión.

Contains fulltext : 215593.pdf (Publisher’s version ) (Closed access) Although blood pressure control is a major goal in chronic kidney disease, no worldwide overview of either its achievement or antihypertensive prescriptions is currently available. To evaluate this we compared crude prevalence of uncontrolled blood pressure among 17 cohort studies, including 34 602 individuals with estimated glomerular filtration rate under 60 ml/min/1.73 m(2) and treated hypertension across four continents, and estimated observed to expected prevalence ratios, adjusted for potential confounders. Crude prevalence of blood pressure of 140/90 mm Hg or more varied from 28% to 61% and of blood pressure of 130/80 or more from 54% to 84%. Adjusted prevalence ratios indicated poorer hypertension control than expected in cohorts from European countries, India, and Uruguay, and better control in patients from North American and high-income Asian countries. Four antihypertensive drug classes or more were prescribed to more than 30% of participants in North American and some European cohorts, but this practice was less common elsewhere. Renin angiotensin-aldosterone system inhibitors were the most common antihypertensive drugs, prescribed for 54% to 91% of cohort participants. Differences for other drug classes were much stronger, ranging from 11% to 79% for diuretics, 22% to 70% for beta-blockers, and 27% to 75% for calcium-channel blockers. The confounders studied explain only a part of the international variation in blood pressure control among individuals with chronic kidney disease. Thus, considerable heterogeneity in prescription patterns worldwide calls for further investigation into the impact of different approaches on patient outcomes.

Background Peritonitis is a major complication and the main cause of peritoneal dialysis (PD) failure. The aim of the present study was to evaluate peritonitis risk factors and its prevention with a new peritoneal educational program (NPEP). Methods We performed a retrospective analysis of a cohort of chronic PD patients, older than 16 years, who began PD in the period 1 January 1999 to 31 December 2015 at a Uruguayan PD center, with follow-up until 31 December 2016. Results The population included 222 cases (219 patients, 128 men), median age 59 (interquartile range [IQR] 47.0 – 72.0) years, median time on PD 17.5 (IQR 6.0 – 36.2) months. Ninety-five patients suffered 1 or more episodes of peritonitis, and they had been on PD for a longer period and had nasal-positive culture more frequently. A NPEP started in September 2008; patients who trained with it, as well as younger patients, had longer peritonitis-free survival. After the NPEP, global peritonitis rates decreased significantly (from 0.48 to 0.29 episodes/patient-year, respectively), particularly gram-positive bacteria and Staphylococcus aureus / coagulase-negative (CoNS) (from 0.26 to 0.12 and 0.21 to 0.07 episodes/patient-year, respectively). In the multivariate Cox analysis of peritonitis risk factors, survival to first peritonitis was significantly associated only with age (hazard ratio [HR] 1.024, 95% confidence interval [CI] 1.007 – 1.397, p = 0.007) and the NPEP (HR 0.600, 95% CI 0.394 – 0.913, p = 0.017). Conclusion A multidisciplinary peritoneal educational program may improve peritonitis rates, independently of other risk factors.

Este documento de recomendaciones tiene como objetivo orientar a médicos nefrólogos y no nefrólogos que asisten a pacientes con enfermedad renal crónica (ERC) en todas las etapas de la misma, en el proceso de vacunación contra el SARS-CoV-2. Como consecuencia de la situación epidemiológica y de los tiempos del proceso de elaboración de las vacunas disponibles, no se ha generado evidencia lo suficientemente potente, por lo que las recomendaciones no se acompañan del nivel de evidencia. Se fundamenta la necesidad de priorizar la vacunación en este grupo de pacientes en el mayor riesgo de adquirir la infección por SARS-CoV-2, desarrollar la enfermedad COVID-19 con mayor gravedad y presentar una mortalidad más elevada que la población general. Las recomendaciones se organizan por grupos de pacientes considerando pacientes con ERC no dialítica, diálisis y trasplante renal, y pacientes bajo tratamiento inmunosupresor.

Uruguay (Republica Oriental del Uruguay) is a South American country (3,505,985 inhabitants, area of 176,215 Km2) where renal replacement therapy for end-stage renal disease has been available for the entire population since 1980. The National Kidney Biopsy Registry was implemented in 1985, the National Renal Healthcare Program providing multidisciplinary care to improve the diagnosis and treatment of patients with chronic renal disease initiated in 2004, and in 2007 the National Integrated Health System (Sistema Nacional Integrado de Salud or SNIS for its Spanish acronym) was established. Nephrological care is widely available for the entire population. Acute and chronic hemodialysis, peritoneal dialysis, and kidney transplantations are available throughout the country. All these treatments are under permanent quality control by health authorities. The Uruguayan Society of Nephrology and the National Resources Fund hold a mandatory registry on dialysis, whereas the Uruguayan Society of Transplantation maintains the Kidney Transplant Registry that includes all kidney transplants performed in the country. In Uruguay, there are 175 practicing nephrologists, 38 hemodialysis centers, 8 peritoneal dialysis centers, and 3 renal transplantation teams. In 2018, the prevalence of dialysis patients was 771 pmp (3069 on hemodialysis and 296 on peritoneal dialysis), and 461 pmp are living with a functioning kidney graft.

Rates of chronic kidney disease (CKD) progression, end stage kidney disease (ESKD), all-cause mortality, and cardiovascular (CVD) events among individuals with CKD vary widely across countries. Well-characterized demographic, comorbidity, and laboratory markers captured for prospective cohorts may explain, in part, such differences. To investigate whether core characteristics of individuals with CKD explain differences in rates of outcomes, we conducted an individual-level analysis of eight studies that are part of iNET-CKD, an international network of CKD cohort studies. Overall, the rate of CKD progression was 40 events/1000 person-year (95% confidence interval 39 - 41), 28 (27 - 29) for ESKD, 41 (40 - 42) for death, and 29 (28 - 30) for CVD events. However, standardized rates were highly heterogeneous across studies (over 92.5%). Interactions by study group on the association between baseline characteristics and outcomes were then identified. For example, the adjusted hazard ratio for CKD progression was 0.44 (95% confidence interval 0.35 - 0.56) for women vs. men among the Japanese (CKD-JAC), while it was 0.66 (0.59 - 0.75) among the Uruguayan (NRHP). The adjusted hazard ratio for ESKD was 2.02 (95% CI 1.88 - 2.17) per 10 units lower baseline eGFR among Americans (CRIC), while it was 3.01 (2.57 - 3.53) among Canadians (CanPREDDICT) (significant interaction for comparisons across all studies). The risks of CKD progression, ESKD, death, and CVD vary across countries even after accounting for the distributions of age, sex, comorbidities, and laboratory markers. Thus, our findings support the need for a better understanding of specific factors in different populations that explain this variation.

Resumen: Introducción: El deterioro de la función renal está asociado a un aumento de la mortalidad en los pacientes con insuficiencia cardíaca (IC). El objetivo de este estudio fue evaluar si la progresión de la enfermedad renal en pacientes estables portadores de IC con fracción de eyección reducida (ICFEr) y enfermedad renal crónica (ERC) se asocia a eventos cardiovasculares (ECV), hospitalización por IC y muerte. Metodología: Estudio de cohorte de seguimiento a 4 años, con análisis en dos etapas: tiempo 1 (inicio del estudio); y tiempo 2 (fin del estudio o muerte). Se definió ICFEr estable como IC con una fracción de eyección del ventrículo izquierdo (FEVI)

Our aim is to describe variations in the incidence rates of glomerular disease diagnosed by renal biopsies performed in Uruguay over the last 25 years in relation to sex, age, clinical presentation and histological diagnosis. We analyzed all renal biopsies performed in Uruguay during the 25 years period and estimated incidence rates per million people per year (pmp/yr) for the population older than 14 years. Mann Kendall's trend analysis was used to assess incidence trends. In order to identify changes in trends, we compared annual incidence rates with the Joinpoint method. From 1990 to 2014, 3390 biopsies of native kidneys corresponding to glomerular disease were performed in patients older than 14 years. The average biopsy rate was 58 per pmp/yr. The glomerular disease incidence rate increased progressively over the period (p

Background Patients on dialysis report high levels of symptom burden. The association of these symptoms may have an increased deleterious effect on the patients' well-being. Objective This study aimed to assess the prevalence of symptoms, to identify symptom clusters, and to describe the impact of concurrent symptoms on physical and emotional well-being in a sample of dialysis patients. Methods Data of the first assessment of a longitudinal study aimed to assess patient-reported outcomes in dialysis were included here. The KDQOL-36 PCS, MCS and Symptom Subscale, the Hospital Anxiety and Depression Scales and the Epworth Sleepiness Scale were analyzed. The ICLUST procedure was followed for hierarchical cluster analyses. Results Of the 512 eligible patients, 493 accepted to participate, 43.6 % were female, with mean age of 60.9 (SD=16.7). Treatment modality was HD in 87.6% of patients. Most prevalent and severe symptoms were muscle sores, cramps, "washed out", dry skin, and itchy skin, Moderate to severe pain was reported by 25%, and daily somnolence by 12.4% of the patients. Five first level symptom clusters were identified as cutaneous, cardiac, digestive, sensory-motor, energy. Both, the presence of any cluster and cluster scores were significantly associated with lower physical and mental quality of life and a higher psychological distress. Conclusions Our study confirms the presence of high symptom burden in dialysis patients in Uruguay. Several symptom clusters were identified having significant impact on the patients' well-being. The identification of symptom clusters can help to understand common underlying pathways. It is possible that the management of symptom clusters may reduce symptom burden in these patients.

Introduction: Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) reduce proteinuria and slow renal disease progression more effectively than other therapies in patients with chronic kidney disease (CKD). However, differences regarding efficacy and safety between these therapies remain controversial. Objectives: Aim of this study was to analyze the different treatment effect of ACEI, ARB, and non-ACEI/ARB in CKD progression. The primary outcome was survival to end-stage renal disease (ESRD) and/or death and to ESRD censored by all-cause death, secondary outcomes were proteinuria reduction and hyperkalemia. Methods: We analyzed data from 1,120 patients extracted from the National Renal Healthcare Program cohort, which included 17,238 CKD nondialysis subjects who were successively monitored between ­September 1, 2004 and August 31, 2016. Inclusion criteria were at least a 1-year follow-up, 3 clinical visits, and no previous treatment with ACEI or ARB. From the baseline visit onward, patients continued with 3 different treatment schemes: no ACEI/ARB, started on ACEI or ARB, but while avoiding both treatments in combination. Chi2, t test, binary logistic regression, and multivariate regression models (Cox proportional Hazard model and competing risk Fine and Gray model were used for statistical analysis. Results: Mean age and follow-up were 67.9 (± 15) and 3.8 (± 2) years, respectively. Estimated glomerular filtration rate averaged 42.1 ± 23 mL/min/1.73 m2 and 300 (27%) patients were diabetics. Progression to ESRD was significantly worse in the no ACEI/ARB group (hazard ratio [HR] 4.23, 95% CI 1.28–13.92) versus ACEI (reference group; p = 0.01). The analysis by competing-risks’ regression showed significantly higher risk of ESRD in the no ACEI/ARB group (HR 3.63, 95% CI 1.34–9.85) versus ACEI (p = 0.01). There were no significant differences between ACEI and ARB groups (HR 1.31, 95% CI 0.37–4.66) regarding the risk of progression to ESRD. Survival was similar in all 3 groups (p = 0.051). Statistically significantly more patients experienced reductions in proteinuria/albuminuria in ACEI and ARB groups (together) versus no ACEI/ARB group (p = 0.016, OR 1.82, 95% CI 1.12–2.94). No difference in hyperkalemia frequency was found between them (p = 0.17). Conclusions: In patients with CKD, treatment with ACEI or ARB had a superior effect than no ACEI or ARB treatment on slowing kidney disease progression and on proteinuria reduction. Efficacy of ACEI and ARB was comparable.

Resumen: La obesidad y el sobrepeso son una pandemia. Algo más de la mitad de los adultos de América Latina tiene sobrepeso y uno de cada cuatro es obeso. En Uruguay la situación es también preocupante. Uno de cada dos adultos tiene sobrepeso y uno de cada cinco obesidad. Sobrepeso y obesidad se vinculan al desarrollo y progresión de enfermedad renal crónica. Esto es consecuencia directa de la obesidad a través de factores mecánicos como la hiperfiltración o el aumento de las presiones cavitarias, o por medio de múltiples mediadores endócrinos e inflamatorios regulados por el tejido adiposo. De forma indirecta la obesidad se vincula al desarrollo de factores de riesgo para enfermedad renal como lo son la diabetes mellitus, la hipertensión arterial, la hiperuricemia y el hígado graso no alcohólico. Por último, algunas patologías como la nefrolitiasis y el desarrollo de neoplasias son más frecuentes en el escenario del sobrepeso y la obesidad, y se vinculan al desarrollo de enfermedad renal. Las medidas tendientes al descenso de peso y la incorporación de hábitos saludables se han vinculado a una reducción en la prevalencia y progresión de la enfermedad renal, así como a mejoría de los marcadores de lesión renal como la proteinuria. La inhibición del eje renina-angiotensina-aldosterona es otra medida eficaz tendiente a disminuir la progresión de la enfermedad renal en esta población. Abstract: Obesity and being overweight are a pandemic. More than half of adults in Latin America are overweight and one in four are obese. In Uruguay, the situation is also worrying. One in two adults is overweight and one in five is obese. Overweight and obesity are linked to the development and progression of chronic kidney disease. This is a direct consequence of obesity through mechanical factors such as hyperfiltration or increased cavitary pressures, or through multiple endocrine and inflammatory mediators regulated by adipose tissue. Indirectly obesity is linked to the development of risk factors for kidney disease such as diabetes mellitus, hypertension, hyperuricemia and non-alcoholic fatty liver. Finally, some pathologies such as nephrolithiasis and the development of neoplasias are more frequent in the scenario of overweight and obesity, and are linked to the development of renal disease. Measures leading to weight loss and the incorporation of healthy habits have been linked to a reduction in the prevalence and progression of renal disease, as well as to an improvement in markers of renal injury such as proteinuria. Inhibition of the renin-angiotensin-aldosterone axis is another effective measure to decrease the progression of renal disease in this population. Resumo: A obesidade e o excesso de peso são uma pandemia. Mais de metade dos adultos na América Latina estão acima do peso e um em cada quatro é obeso. No Uruguai, a situação também é preocupante. Um em cada dois adultos tem excesso de peso e um em cada cinco é obeso. Sobrepeso e obesidade estão ligados ao desenvolvimento e progressão da doença renal crônica. Esta é uma conseqüência direta da obesidade através de fatores mecânicos como hiperfiltração ou aumento das pressões cavitárias, ou através de múltiplos mediadores endocrinos e inflamatórios regulados pelo tecido adiposo. Indiretamente, a obesidade está ligada ao desenvolvimento de fatores de risco para doenças renais como diabetes mellitus, hipertensão, hiperuricemia e fígado gordo não alcoólico. Finalmente, algumas patologias como nefrolitíase e desenvolvimento de neoplasias são mais freqüentes no cenário de sobrepeso e obesidade e estão ligadas ao desenvolvimento de doença renal. As medidas que levaram à perda de peso e à incorporação de hábitos saudáveis têm sido associadas a uma redução na prevalência e progressão da doença renal, bem como a uma melhora nos marcadores de lesão renal, como a proteinúria. A inibição do eixo renina-angiotensina-aldosterona é outra medida efetiva para diminuir a progressão da doença renal nesta população.

Introduction Because of their rarity in men, systemic lupus erythematous and lupus nephritis (LN) are poorly understood in men. Our aim was to analyze the clinical presentation and course of histology-proven systemic lupus erythematous and LN in males and to determine the risk factors for progression to end-stage renal disease. Methods Fifty patients from 2 historical cohorts in Spain (Hospital 12 de Octubre) and Uruguay were retrospectively analyzed and compared with a female cohort matched for age and disease characteristics. Results The median age at the time of renal biopsy was 27 years (range, 8–79 years). The main forms of presentation were nephrotic syndrome in 26 of 50 patients (52%), and class IV LN in 34 of 50 (68%). After treatment, 21 patients (45.6%) achieved complete renal remission. During follow-up, 12 patients required renal replacement therapy, and 3 patients died of infectious causes. When patients who required renal replacement therapy were compared with those who did not require it, several parameters showed significant differences (P < 0.05) at the time of renal biopsy: estimated glomerular filtration rate < 60 ml/min, hypertension, hypoalbuminemia, and concomitant visceral involvement (neurologic, cardiovascular, and/or pulmonary). In the multivariate analysis, only estimated glomerular filtration rate < 60 ml/min persisted as a risk factor for progression to end-stage renal disease. When compared with a cohort of female patients with LN, there were no significant differences in remission or renal survival. Discussion LN in males usually presents as nephrotic syndrome, and type IV LN is the most frequent form. An estimated glomerular filtration rate < 60 ml/min at the time of renal biopsy is associated with poor renal outcomes. There were no differences in remission or progression of LN in males when compared with a cohort of female patients with LN.

Summary Since 1980, Uruguay has universal access to renal replacement therapy. Prevalence of end-stage renal disease is 756 pmp. The aim of this study was to estimate prevalence of nondialysis chronic kidney disease Stages I to V. Databases used for the population aged 15–64 were three: the 2011 National Census, the National Survey on Non Communicable Disease Risk Factors (n 2.564) and preventive Health Check-ups (n 10.542). Estimated prevalence of proteinuria ≥0.3 g/L (urine test trips) was 5.98%. Persistent proteinuria was 16% and was associated with age (RR 8.63 in age group 70 and above, vs. 15–24 years of age), diabetes (RR 2.9) and high blood pressure (RR 1.79). Prevalence of estimate glomerular filtration rate (eGFR) In population aged 65 and above CKD prevalence was estimated from Uruguay Kidney Health Programme (PSRU) (18.570 CKD patients) and Uruguayan Registry of Dialysis. The estimated prevalence of CKD patients Stages IV and V on the whole population of Uruguay was as follows: 2.29% on age group 65 and above, and 0.15% on age group under 65.

Rhabdomyolysis results from acute necrosis of skeletal muscle fibers and consequent leakage of muscle constituents into the circulation. It ranges from an asymptomatic state to a severe condition associated with extreme elevations in creatine kinase and acute renal failure. Reported etiologies of rhabdomyolysis include alcohol abuse, drugs, muscle trauma and muscle overexertion. Less common causes include muscle enzyme deficiencies, electrolyte abnormalities, infectious causes, toxins and endocrine disorders. Hypokalemia is a rare cause of rhabdomyolysis. We report six patients aged 31 to 57 years (three women) with a severe hypokalemic rhabdomyolysis, secondary to chronic diarrhea in two patients, treatment with loop diuretics in one and Gitelman syndrome in three. Rhabdomyolysis may be underdiagnosed in the context of hypokalemia, because the neuromuscular symptoms can be attributed solely to the electrolyte disorder.

Background & Aim In recent years, many studies have shown that bone marrow mesenchymal stromal cells (BM-MSCs) promote renal recovery and prevent renal damage. In an irreversible unilateral ureteral obstruction (UUO) model, less damage has been reported in rats treated with BM-MSCs after one or two weeks of administration. However, effects in the contralateral kidney had not been studied. The aim of this study is to evaluate the effect of BM-MSCs and CM in attenuating parenchymal damage in an irreversible unilateral ureteral obstruction model (obstructed and contralateral kidney). Methods, Results & Conclusion Methodology BM-MSCs were obtained by primary culture of bone marrow of male Wistar rats, characterized by flow cytometry (CD45-, CD90+, CD 29+) and then administered in passages 2 to 6. Female Wistar rats were divided in 4 groups for treatment under anesthesia and maximum asepsis: 1) Sham operated: median ventral incision and closure by planes (n=6); 2) UUO: Unilateral ureteral obstruction (n=6); 3) UUO + BM-MSC: Unilateral ureteral obstruction with immediate administration of 1 × 106 BM-MSC, by puncture of inferior vena cava (n=7) and 4) UUO + CM: Unilateral ureteral obstruction with immediate administration of 400 µl of conditioned medium (CM) by puncture of inferior vena cava (n=5). At 2 weeks, blood was extracted from the aorta to evaluate creatinine levels and both kidneys were excised. Semi-quantitative (PAS and H&E) and immunohistochemical (Alpha-smooth-muscle actin, E-cadherin and nitrotyrosine) scores were analyzed to evaluate epithelial-mesenchymal transition and nitro-oxidative injury. Statistical analysis was performed by using the t-tests and one way ANOVA with Tukey post hoc test as appropriate. A p-value of Results The administration of BM-MSC in a model of irreversible unilateral ureteral obstruction is associated with a lower creatinine level and less nitrooxidative injury in the contralateral kidney at day 14 (p Conclusion BM-MSC and CM could effectively preserve kidney function in an unilateral obstruction model by protecting the contralateral kidney against nitro-oxidative injury. These results suggest a potential clinical treatment for chronic kidney diseases. This nephroprotective effect can be attributed to the antioxidant and anti-inflammatory activities of BM-MSC and CM.

♦Objectives The present study evaluated the tool used to assess patients’ skills and the impact on peritonitis rates of a new multidisciplinary peritoneal dialysis (PD) education program (PDEP). ♦Methods After the University Hospital Ethics Committee approved the study, the educational and clinical records of PD patients were retrospectively analyzed in two phases. In phase I, an Objective Structured Assessment (OSA) was used during August 2008 to evaluate the practical skills of 25 patients with adequate Kt/V and no mental disabilities who had been on PD for more than 1 month. Test results were correlated with the prior year's peritonitis rate. In phase II, the new PDEP, consisting of individual lessons, a retraining schedule, and group meetings, was introduced starting 1 September 2008. Age, sex, years of education, time on PD, number of training sessions, and peritonitis episodes were recorded. Statistical analyses used t-tests, chi-square tests, and Poisson distributions; a p value of less than 0.05 was considered significant. ♦Results In phase I, 25 patients [16 men, 9 women; mean age: 54 ± 15 years (range: 22 – 84 years); mean time on PD: 35 ± 30 months (range: 1 – 107 months)] were studied. The OSA results correlated with peritonitis rates: patients who passed the test had experienced significantly lower peritonitis rates during the prior year ( p < 0.05). In phase II, after the new PDEP was introduced, overall peritonitis rates significantly declined (to 0.28 episodes/patient–year from 0.55 episodes/patient–year, p < 0.05); the Staphylococcus peritonitis rate also declined (to 0.09 episodes/patient–year from 0.24 episodes/patient–year, p < 0.05). ♦Conclusions The OSA is a reliable tool for assessing patients’ skills, and it correlates with peritonitis rates. The multidisciplinary PDEP significantly improved outcomes by further lowering peritonitis rates.

The Chronic Kidney Disease (CKD) Prognosis Consortium is a collaborative author of the above-mentioned article. The CKD Prognosis Consortium investigators/collaborators are as follows: • African American Study of Kidney Disease and Hypertension (AASK): Brad Astor, Lawrence J. Appel; British Columbia CKD Study (BC CKD): Adeera Levin, Ognjenka Djurdjev; Canadian Study of Prediction of Death, Dialysis and Interim Cardiovascular Events (CanPREDDICT): Adeera Levin, Mila Tang, Ognjenka Djurdjev; Cleveland Clinic CKD Registry Study (CCF): Sankar D. Navaneethan, Stacey E. Jolly, Jesse D. Schold, Joseph V. Nally Jr; Chronic Renal Impairment in Birmingham (CRIB): David C. Wheeler, Jonathan Emberson, John Townend, Martin Landray; Chronic Renal Insufficiency Cohort Study (CRIC): Harold I. Feldman, Chi-yuan Hsu, James P. Lash, Lawrence J. Appel; Chronic Renal Insufficiency Standards Implementation Study (CRISIS): Philip A. Kalra, James P. Ritchie, Raman Maharajan, Helen Alderson, Beverly Lane; German Chronic Kidney Disease Study (GCKD): Kai-Uwe Eckardt, Markus P. Schneider, Anna Kottgen, Florian Kronenberg, Barbara Barthlein; Geisinger Health System: Alex R. Chang, Jamie A. Green, H. Lester Kirchner, Kevin Ho; Grampian Laboratory Outcomes, Morbidity and Mortality Studies – 2 (GLOMMS2): Angharad Marks, Corri Black, Gordon J. Prescott, Nick Fluck; Gonryo Study: Masaaki Nakayama, Mariko Miyazaki, Tae Yamamoto, Gen Yamada; Hong Kong CKD Studies: Angela Yee-Moon Wang, Sharon Cheung, Sharon Wong, Jessie Chu, Henry Wu; Maccabi Health System: Varda Shalev, Gabriel Chodick; Multifactorial Approach and Superior Treatment Efficacy in Renal Patients with the Aid of a Nurse Practitioner (MASTERPLAN): Peter J. Blankestijn, Jack F.M. Wetzels, Arjan D. van Zuilen, Jan A. van den Brand; Modification of Diet in Renal Disease Study (MDRD): Andrew S. Levey, Lesley A. Inker, Mark J. Sarnak, Hocine Tighiouart; Nanjing CKD Network Cohort Study (Nanjing CKD): Haitao Zhang; NephroTest Study: Benedicte Stengel; National Renal Healthcare Program – Uruguay (NRHP-URU): Pablo G. Rios, Nelson Mazzuchi, Liliana Gadola, Veronica Lamadrid, Laura Sola; New Zealand Diabetes Cohort Study (NZDCS): John F. Collins, C. Raina Elley, Timothy Kenealy; Parcours de Soins des Personnes Agees (PSPA): Olivier Moranne, Cecile Couchoud, Cecile Vigneau; Primary-Secondary Care Partnership to Prevent Adverse Outcomes in Chronic Kidney Disease (PSP CKD): Nigel J. Brunskill, Rupert W. Major, David Shepherd, James F. Medcalf; Racial and Cardiovascular Risk Anomalies in CKD Cohort (RCAV): Csaba P. Kovesdy, Kamyar Kalantar-Zadeh, Miklos Z. Molnar, Keiichi Sumida, Praveen K. Potukuchi; Reduction of Endpoints in Non-insulin Dependent Diabetes Mellitus with the Angiotensin II Antagonist Losartan (RENAAL): Hiddo J.L. Heerspink, Dick de Zeeuw, Barry Brenner; Stockholm CREAtinine Measurements Cohort (SCREAM): Juan Jesus Carrero, Peter Barany, Abdul Rashid Qureshi, Carl-Gustaf Elinder; Second Manifestations of ARTerial Disease Study (SMART): Frank L.J. Visseren, Yolanda van der Graaf; Swedish Renal Registry CKD Cohort (SRR CKD): Marie Evans, Maria Stendahl, Staffan Schon, Marten Segelmark, Karl-Goran Prutz; Sunnybrook Cohort: David M. Naimark, Navdeep Tangri; West of Scotland CKD Study: Patrick B. Mark, Jamie P. Traynor, Colin C. Geddes, Peter C. Thomson.• CKD Prognosis Consortium Steering Committee: Alex R. Chang, Josef Coresh (Chair), Ron T. Gansevoort, Morgan E. Grams, Anna Kottgen, Andrew S. Levey, Kunihiro Matsushita, Mark Woodward, Luxia Zhang.• CKD Prognosis Consortium Data Coordinating Center: Shoshana H. Ballew (Assistant Project Director), Jingsha Chen (Programmer), Josef Coresh (Principal Investigator), Morgan E. Grams (Director of Nephrology Initiatives), Lucia Kwak (Programmer), Kunihiro Matsushita (Director), Yingying Sang (Lead Programmer), Aditya Surapaneni (Programmer), Mark Woodward (Senior Statistician).• Kidney Disease Improving Global Outcomes (KDIGO) Controversies Conference on Prognosis and Optimal Management of Patients with Advanced CKD: Kai-Uwe Eckardt (Conference Co-Chair), Brenda R. Hemmelgarn (Conference Co-Chair), David C. Wheeler (KDIGO Co-Chair), Wolfgang C. Winkelmayer (KDIGO Co-Chair), John Davis (CEO), Danielle Green (Managing Director), Michael Cheung (Chief Scientific Officer), Tanya Green (Communications Director), Melissa McMahan (Programs Director).

Calcium citrate ameliorates the progression of chronic renal injury.BackgroundMetabolic acidosis is a consequence of chronic renal failure and it may produce bone demineralization, muscle proteolysis, and progression of chronic renal failure. The aim of this study was to evaluate the effects of correction of metabolic acidosis with calcium citrate in an experimental model of renal mass ablation.MethodsWistar rats were subjected to 5/6 nephrectomy and were randomly assigned to one of 4 groups: nontreated (NFX); treated with calcium citrate (1.45g/100g feed) (NFX-CIT); treated with captopril (500mg/L water) (NFX-CAP); or treated with both (NFX-CAP-CIT) during 1, 10, or 20weeks. Body weight, systolic blood pressure, proteinuria, arterial bicarbonate concentration, urine citrate excretion, plasma calcium, and inulin clearance were measured. Histologic glomerular and tubulointerstitial damage scores were measured at 1, 10, and 20weeks, and glomerular and tubular proliferating cell nuclear antigen (PCNA)-positive cells, α-smooth muscle actin, and desmin staining were studied by immunohistochemistry at 1 and 10weeks.ResultsThe treated groups showed significantly less glomerular and tubulointerstitial cellular proliferation in the first week (P < 0.05), less glomerular cell transdifferentiation and higher plasma bicarbonate at 10weeks (P < 0.05), as well as diminished histologic glomerular and tubulointerstitial damage scores at 20weeks (P < 0.05). Inulin clearances were higher (P < 0.05), and urine protein excretion rates were lower (P < 0.05) than in the NFX non-treated group, but arterial blood pressure was not significantly different in the NFX-CIT group.ConclusionCalcium citrate slows the progression of chronic renal injury in the 5/6 NFX model. It improves metabolic acidosis and diminishes cell proliferation and transdifferentiation without changes in systolic blood pressure.

Background. Estimation of glomerular filtration rate (eGFR) from biomarkers has evolved and multiple equations are available to estimate renal function at bedside.Methods. In a random sample of 119 Uruguayans (54.5% women; 56.2 years (mean)), we used Bland and Altman’s method and Cohen’s kappa statistic to assess concordance on a continuous or categorical (eGFR < 60versus≥60 mL/min/1.73 m2) scale between eGFRcys(reference) and eGFR derived from serum creatinine according to the Modification of Diet in Renal Disease (eGFRmdrd) or the Chronic Kidney Disease Epidemiology Collaboration equations (eGFRepi) or from both serum cystatin C and creatinine (eGFRmix).Results. In all participants, eGFRmdrd, eGFRepi, and eGFRmixwere, respectively, 9.7, 11.5, and 5.6 mL/min/1.73 m2higher (P<0.0001) than eGFRcys. The prevalence of eGFR 2was the highest for eGFRcys(21.8%), intermediate for eGFRmix(11.8%), and the lowest for eGFRmdrd(5.9%) and eGFRepi(3.4%). Using eGFRcysas reference, we found only fair agreement with the equations based on creatinine (Cohen’s kappa statistic 0.15 to 0.23).Conclusion. Using different equations we reached clinically significant differences in the estimation of renal function. eGFRcysprovides lower estimates, resulting in higher prevalence of eGFR 2.

Rhabdomyolysis results from acute necrosis of skeletal muscle fibers and consequent leakage of muscle constituents into the circulation. It ranges from an asymptomatic state to a severe condition associated with extreme elevations in creatine kinase and acute renal failure. Reported etiologies of rhabdomyolysis include alcohol abuse, drugs, muscle trauma and muscle overexertion. Less common causes include muscle enzyme deficiencies, electrolyte abnormalities, infectious causes, toxins and endocrine disorders. Hypokalemia is a rare cause of rhabdomyolysis. We report six patients aged 31 to 57 years (three women) with a severe hypokalemic rhabdomyolysis, secondary to chronic diarrhea in two patients, treatment with loop diuretics in one and Gitelman syndrome in three. Rhabdomyolysis may be underdiagnosed in the context of hypokalemia, because the neuromuscular symptoms can be attributed solely to the electrolyte disorder.

INTRODUCTION: Epithelial-to-mesenchymal transition (EMT) is a key event in renal fibrosis. The aims of the study were to evaluate acidosis induced EMT, transforming-growth-factor (TGF) β1 role and citrate effect on it. METHODS: HK2 cells (ATCC 2290) were cultured in DMEM/HAM F12 medium, pH 7.4. At 80% confluence, after 24 hr under serum free conditions, cells were distributed in three groups (24 hours): A) Control: pH 7.4, B) Acidosis: pH 7.0 and C) Calcium citrate (0.2 mmol/L) + pH 7.0. Change (Δ) of intracellular calcium concentration, basal and after Angiotensin II (10-6M) exposition, were measured to evaluate cellular performance. EMT was evaluated by the expression of α-smooth muscle actin (α-SMA) and E-cadherin by immunocytochemistry and/or Western blot. TGF-β1 secretion was determined by ELISA in cell supernatant. RESULTS: At pH 7.0 HK2 cells significantly reduced E-cadherin and increased α-SMA expression (EMT). Supernatant TGF-β1 levels were higher than in control group. Calcium citrate decreased acidosis induced EMT and improved cells performance, without reduction of TGF-β production. CONCLUSIONS: Acidosis induces EMT and secretion of TGF-β1 in tubular proximal cells in culture and citrate improves cellular performance and ameliorates acidosis induced EMT.

Uruguay is a South American country (3241003 inhabitants) where renal replacement treatment is universally available. The aim of this study was to analyze the incidence and outcome of peritonitis, and the causative organisms and their sensitivity, in order to recommend an empiric initial antibiotic treatment. A retrospective descriptive study of all peritonitis during the period 2004 – 2005 was performed (144 peritonitis, 44% due to gram-positive bacteria). We conclude that the high prevalence of methicillin-resistant coagulase-negative staphylococci justifies the use of vancomycin in the national empiric initial antibiotic protocols.

A multicenter cross-sectional study was performed to evaluate the prevalence of heart failure (HF) and the associated cardiovascular (CV) risk factors in 298 peritoneal dialysis (PD) patients from Argentina and Uruguay, representing almost 30% of the total number of PD patients in the two countries. Bidimensional echocardiography, electrocardiography, and biochemical analysis were performed. Systolic HF was defined as an ejection fraction50%. According to echocardiography, 84.6% showed left ventricular hypertrophy (LVH), 38.3% valvular heart disease, and 35.4% valvular calcification, whereas 20% showed intraventricular conduction disturbances on the electrocardiogram. The prevalence of CV risk factors was of 73% hypertension, 51% sedentarism, 18% diabetes, 16.8% obesity, 12% smokers, 42.3% phosphorus5.5 mg per 100 ml, 42.3% parathyroid hormone300 pg ml(-1), and 29.6% calcium phosphate product55. The prevalence of systolic HF was 9.9%, being significantly associated with diabetes: odds ratio (OR)=4.11 (P0.006) and hypoalbuminemia: OR=3.45 (P0.011). Forty percent of patients with a diagnosis of left ventricular dysfunction at the time of the study were asymptomatic. Variables associated with LVH in the multivariate analysis were anemia (OR=4.06; P0.001) and previous hemodialysis (OR=1.99; P0.031). The identification of reversible risk factors associated to HF and the diagnosis of asymptomatic ventricular dysfunction in this PD population will lead our efforts to establish guidelines for prevention and early treatment of congestive HF in patients on PD.