Search

A variação da prática clínica é um fenómeno que se encontra bem descrito e que se caracteriza por uma prática clínica utilizando testes diagnósticos e esquemas terapêuticos diversos, em doentes semelhantes na patologia que apresentam e no seu risco basal. A sobreutilização de recursos em saúde caracteriza-se por apresentar um benefício-risco negativo. Infelizmente ambos os fenómenos se verificam em diversos países, em particular países desenvolvidos. Neste contexto, o American Board of Internal Medicine lançou a campanha Choosing Wisely, a qual foi, entretanto, implementada em diversos países incluindo Portugal. The variation of clinical practice is a well-described phenomenon in which patients with similar diagnoses, prognoses and demographic status receive different levels of care depending on when, where and by whom they are treated, despite agreed and documented evidence of best practice. The overutilization of health resources is also known to have a negative risk-benefit ratio. Unfortunately, both phenomena occur in several countries, especially in developed countries. In the light of this, the American Board of Internal Medicine launched the Choosing Wisely campaign, which has subsequently been implemented in several countries, including Portugal. info:eu-repo/semantics/publishedVersion

BACKGROUND The global prevalence of Chronic Kidney Disease (CKD) is rising exponentially, although its real prevalence is underestimated. We aimed to identify which areas related to CKD should be the subject of educational or research programs. OBJECTIVE The main goal of this study is to identify which areas related to CKD should be the subject of educational or research programs. METHODS Participants with experience in scientific production and who consider CKD as an area of interest were recruited (44 from primary care and 52 from secondary care) and divided into two groups. In the Awareness Round they answered four open short-answer questions leading to statements and in the Consensus Round they were asked to rate their level of agreement with the statements using a five-point Likert scale - the Jandhyala method. RESULTS In general, the results showed a low awareness of some entities, such as Polycystic kidney disease, glomerulopathies and acute kidney disease. Referral was the item where there was a lower consensus index, especially in primary care. Awareness and therapeutic inertia had a high awareness and consensus indexes, which represented a recognition of sometimes inadequate perception of the problem by colleagues and failure to apply appropriate diagnostic measures. The prescription of nephroprotective drugs, the avoidance of nephrotoxic drugs and referral had a low awareness index and a higher consensus and Index Score, while in secondary care, their index score was much lower. CONCLUSIONS There is a need to advocate for equitable and affordable access to the entire spectrum of kidney care everywhere and more studies to assess and reassess cost-effectiveness of screening and treatment of CKD in the light of new therapeutics. Based on our results, there is a high likelihood of success in implementing outreach projects or initiatives focused on CKD literacy, referral and disease management.

© 2020 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved., The concept of Less is More medicine emerged in North America in 2010. It aims to serve as an invitation to recognize the potential risks of overuse of medical care that may result in harm rather than in better health, tackling the erroneous assumption that more care is always better. In response, several medical societies across the world launched quality-driven campaigns (“Choosing Wisely”) and published “top-five lists” of low-value medical interventions that should be used to help make wise decisions in each clinical domain, by engaging patients in conversations about unnecessary tests, treatments and procedures. However, barriers and challenges for the implementation of Less is More medicine have been identified in several European countries, where overuse is rooted in the culture and demanded by a society that requests certainty at almost any cost. Patients’ high expectations, physician's behavior, lack of monitoring and pernicious financial incentives have all indirect negative consequences for medical overuse. Multiple interventions and quality-measurement efforts are necessary to widely implement Less is More recommendations. These also consist of a top-five list of actions: (1) a novel cultural approach starting from medical graduation courses, up to (2) patient and society education, (3) physician behavior change with data feedback, (4) communication training and (5) policy maker interventions. In contrast with the prevailing maximization of care, the optimization of care promoted by Less is More medicine can be an intellectual challenge but also a real opportunity to promote sustainable medicine. This project will constitute part of the future agenda of the European Federation of Internal Medicine.

High levels of FGF23 associate with adverse events in CKD. The urinary fractional excretion of phosphate (FePi) might modify this association, although data are limited in moderate and advanced CKD. We investigated the association of combined FePi and serum FGF23 with incident heart failure, cardiovascular events and mortality in patients with CKD stages 2-4.Patients from the Chronic Renal Insufficiency Cohort were divided into four groups according to the median of FePi and FGF23: low-FePi/low-FGF23, reference group; high-FePi/low-FGF23; low-FePi/high-FGF23; high-FePi/high-FGF23. Primary outcomes were: the composite of cardiovascular death or hospitalization for heart failure; cardiovascular death; hospitalization for heart failure; and death from any cause. Survival analysis and adjusted regression analyses were performed.We analyzed 3684 patients with a mean age of 58 ± 11 years of whom 45% were male. Mean eGFR was 44 ± 15 ml/min/1.73 mHigh FGF23 was associated with heart failure and cardiovascular death in patients with low FePi and high FePi with moderate to advanced CKD. This contrasts with reports in mild CKD.

Purpose Despite our understanding of diabetes as an established risk factor for progressive kidney disease and cardiac complications, the prognostic significance of prediabetes in patients with chronic kidney disease (CKD) remains largely unknown. Methods Participants of the Chronic Renal Insufficiency Cohort (CRIC) were categorized as having normoglycemia, prediabetes, or diabetes according to fasting plasma glucose, glycated hemoglobin A1c (HbA1c), and treatment with antidiabetic drugs at baseline. Unadjusted and adjusted proportional hazards models were fit to estimate the association of prediabetes and diabetes (versus normoglycemia) with: (1) composite renal outcome (end-stage renal disease, 50% decline in estimated glomerular filtration rate to ≤ 15 mL/min/1.73 m2, or doubling of urine protein-to-creatinine ratio to ≥ 0.22 g/g creatinine); (2) composite cardiovascular (CV) outcome (congestive heart failure, myocardial infarction or stroke); and (3) all-cause mortality. Results Of the 3701 individuals analyzed, 945 were normoglycemic, 847 had prediabetes and 1909 had diabetes. The median follow-up was 7.5 years. Prediabetes was not associated with the composite renal outcome (adjusted hazard ratio [aHR] 1.13; 95% confidence interval [CI], 0.96–1.32; P = 0.14), but was associated with proteinuria progression (aHR 1.23; 95% CI, 1.03–1.47; P = 0.02). Prediabetes was associated with a higher risk of the composite CV outcome (aHR 1.38; 95% CI, 1.05–1.82; P = 0.02) and a trend towards all-cause mortality (aHR 1.28; 95% CI, 0.99–1.66; P = 0.07). Participants with diabetes had an increased risk of the composite renal outcome, the composite CV outcome, and all-cause mortality. Conclusions In individuals with CKD, prediabetes was not associated with composite renal outcome, but was associated with an increased risk of proteinuria progression and adverse CV outcomes.

Introduction The clinical-histologic correlation in diabetic nephropathy is not completely known. Methods We analyzed nephrectomy specimens from 90 patients with diabetes and diverse degrees of proteinuria and glomerular filtration rate (GFR). Results Thirty-six (40%) subjects had normoalbuminuria, 33 (37%) microalbuminuria, and 21 (23%) non-nephrotic proteinuria. Mean estimated GFR (eGFR) was 65±23 (40% 10% to 20% of the sample. Moderate hyalinosis and arteriolar sclerosis were observed in 80% to 100% of cases with normoalbuminuria, microalbuminuria, proteinuria, as well as in class I, II, or III. Conclusions Weak correspondence between analytical parameters and kidney histology was found. Thus, disease may progress undetected from the early clinical stages of the disease. Finally, vascular damage was a very common finding, which highlights the role of ischemic intrarenal disease in diabetes., Graphical abstract

Background and Aims Antineutrophil cytoplasmic antibody-associated vasculitis (AAV) and anti-glomerular basement membrane (GBM) disease are autoimmune diseases frequently associated with poor renal outcomes namely hemodialysis. Therefore, the aim of this study was to identify predictors of renal replacement therapy (RRT) at six months in patients with ANCA-associated vasculitis and/or anti-glomerular basement membrane disease. Method We performed a single center observational, retrospective study in 40 patients with ANCA-associated vasculitis and/or anti-GBM disease diagnosed between January 2013 and June 2019. Clinical, analytical and histological variables were included as well as therapeutic regimens and outcomes. The primary endpoint was renal replacement therapy (RRT) at six months. Continuous variables were presented as means or medians, according to normality and categorical variables presented as frequencies. The comparison between subgroups of patients was performed using the Wilcoxon, Fisher exact test or t-test, chi-square test, according to normality. Univariate logistic regression model was fitted to identify variables associated with renal replacement therapy. STATA 14.2 statistical package was used and p Results We identified 40 patients, with a mean age of 69 years-old, 18 (45%) were male, 37 (95%) Caucasian. Twenty-seven (68%) had hypertension and 3 (8%) diabetes. The majority (33, 83%) presented with constitutional symptoms. Pulmonary manifestations were seen in 12 (30%) and gastrointestinal in 5 patients (12%). The other symptoms were rare. The mean systolic blood pressure was 140 mmHg and mean diastolic blood pressure 73 mmHg. The mean hemoglobin in hospital stay was 9,4g/dL, albumin 3.0 mg/dL, erythrocyte sedimentation rate 77mm/h, C3 1,11 UQ, C4 0,30 UQ, proteinuria 1,42 gr/24h, hematuria 279 erythrocytes, serum creatinine 3,4 mg/dL, eGFR 14 ml/min/m2, uric acid 7.1 mg/dL. The average ANCA MPO titles were 382 UQ/L, PR3 751UQ/L and GBM 883UQ/L. During hospital stay 11 patients (28%) needed dialysis. Renal biopsy showed interstitial fibrosis and tubular atrophy grade 0 in 5 patients (13%), grade 1 in 13(33%), grade 2 in 8 (20%) and grade 3 in 14 (35%). The majority had no vessel involvement 24 (60%). Acute tubular necrosis was absent in 13 (33%) patients, grade 1 in 9 (23%) and grade 2 in 18 (45%). Inflammatory infiltrate was present in 25 patients (63%). Regarding treatment, 38 (95%) of patients received pulse methylprednisolone and all prednisolone. Rituximab was administered to 15 (38%) patients and Cyclophosphamide to 14 (35%). Eighteen (45%) received azathioprine and 3 (8%) mycophenolate mofetil. Plasmapheresis was performed in 14 patients (35%). The average time from beginning of symptoms to treatment initiation was 119 days. The mean follow-up was 1094 days. At discharge the mean serum creatinine was 2,5 mg/dL, eGFR 23ml/min/m2 and none of the patients died. At six months, mean serum creatinine was 1.6 mg/dL, eGFR 31ml/min/m2 but 15 (38%) patients were dialysis-dependent. Two relapses occurred and 17 (43%) had infections during this period. Five (13%) patients died. At 12 months, mean serum creatinine was 2.0 mg/dL, eGFR 29 ml/min/m2 and (9) 23% patients were dialysis dependent. Six (30%) patients had infections and 5 (13%) died. In the end of follow up 13 (33%) patients had died. On univariate analysis, hemoglobin (OR 0.59 [0.36-0.95], p = 0.031), uric acid (OR 1.85 [1.12-3.05], p = 0.027), hematuria (OR 1.00 [1.00-1.00], p = 0.013), hemodialysis performed during 1st hospital stay (OR 22.9 [2.3-217.9], p = 0.006) and plasmapheresis ( OR 12.0 [2.4-61.0], p = 0.003) were associated with RRT at six months. Conclusion RRT in AAV and anti-GBM disease has decreased over the last decades with the use of immunosuppressive therapies. Clinical presentation and plasmapheresis seem the major predictors for RRT.

Background An inverse relationship between coffee consumption and mortality has been reported in the general population. However, the association between caffeine consumption and mortality in patients with chronic kidney disease (CKD) remains uncertain. Methods We analysed 4863 non-institutionalized USA adults with CKD [defined by an estimated glomerular filtration rate (eGFR) of 15–60 mL/min/1.73 m2 and/or a urinary albumin:creatinine ratio >30 mg/g] in a nationwide study using the National Health and Nutrition Examination Survey (NHANES) 1999–2010. Caffeine consumption was evaluated by 24-h dietary recalls at baseline and all-cause, cardiovascular and cancer mortality were evaluated until 31 December 2011. We also performed an analysis of caffeine consumption according to its source (coffee, tea and soft drinks). Quartiles of caffeine consumption were 213.5 (Q4). Results During a median follow-up of 60 months, 1283 participants died. Comparing with Q1 of caffeine consumption, the adjusted hazard ratio for all-cause mortality was 0.74 [95% confidence interval (CI) 0.60–0.91] for Q2, 0.74 (95% CI 0.62–0.89) for Q3 and 0.78 (95% CI 0.62–0.98) for Q4 (P = 0.02 for trend across quartiles). There were no significant interactions between caffeine consumption quartiles and CKD stages or urinary albumin:creatinine ratio categories regarding all-cause mortality. Conclusions We detected an inverse association between caffeine consumption and all-cause mortality among participants with CKD.

The variation of clinical practice is a well-described phenomenon in which patients with similar diagnoses, prognoses and demographic status receive different levels of care depending on when, where and by whom they are treated, despite agreed and documented evidence of best practice. The overutilization of health resources is also known to have a negative risk-benefit ratio. Unfortunately, both phenomena occur in several countries, especially in developed countries. In the light of this, the American Board of Internal Medicine launched the Choosing Wisely campaign, which has subsequently been implemented in several countries, including Portugal.A variação da prática clínica é um fenómeno que se encontra bem descrito e que se caracteriza por uma prática clínica utilizando testes diagnósticos e esquemas terapêuticos diversos, em doentes semelhantes na patologia que apresentam e no seu risco basal. A sobreutilização de recursos em saúde caracteriza-se por apresentar um benefício-risco negativo. Infelizmente ambos os fenómenos se verificam em diversos países, em particular países desenvolvidos. Neste contexto, o American Board of Internal Medicine lançou a campanha Choosing Wisely, a qual foi, entretanto, implementada em diversos países incluindo Portugal.

Copyright © 2019 Endocrine Society, Purpose: Diabetes mellitus is a risk factor for the development and progression of chronic kidney disease (CKD). However, the association of prediabetes with adverse kidney outcomes is uncertain. Methods: We performed a secondary analysis of the Systolic Blood Pressure Intervention Trial (SPRINT), including 9,361 participants without diabetes at baseline. We categorized participants according to fasting glucose as having impaired fasting glucose (≥100 mg/dL [(≥5.6 mmol/L]) or normoglycemia (10 mg/g). These outcomes were also evaluated separately, and according to CKD status at baseline. Results: The mean age was 67.9 ± 9.4 years, 35.5% were female, and 31.4% were black. The median follow-up was 3.3 years and 41.8% had impaired fasting glucose. Impaired fasting glucose was not associated with higher rates of the composite outcome (HR 0.97; 95%CI 0.81-1.16), worsening kidney function (HR 1.02; 95%CI 0.75-1.37), or albuminuria (HR 0.98; 95%CI 0.78-1.23). Similarly, there was no association of impaired fasting glucose with outcomes according to baseline CKD status. Conclusions: Impaired fasting glucose at baseline was not associated with the development of worsening kidney function or albuminuria in participants of SPRINT., The SPRINT trial was sponsored by the National Heart, Lung, and Blood Institute (NHLBI), with cosponsorship by the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institute of Neurological Disorders and Stroke, and the National Institute on Aging. F.R.M. is supported by the National Institute of Diabetes and Digestive and Kidney Diseases grant K23DK102511.

Portugal presents the highest incidence of stage 5 chronic kidney disease in Europe. It is speculated that a high consumption of non-steroidal anti-inflammatory drugs (NSAIDS) may contribute to this high incidence. Our aim was to characterize the prescription of non-steroidal anti-inflammatory drugs to patients with diabetes mellitus in Portugal.We analyzed the national prescription database in triennium 2015 - 2017. In patients with diabetes mellitus, we evaluated the prescription of non-steroidal anti-inflammatory drugs according to age, gender and region of the patient and specialty of the prescribing physician. We evaluated the prescription of non-steroidal anti-inflammatory drugs in all patients with diabetes mellitus, in patients with presumed renal impairment, and in those with concomitant prescription of angiotensin converting enzyme inhibitors or angiotensin receptor antagonists.We analyzed 23 320 620 prescriptions, corresponding to 610 157 adults, including 104 306 patients with diabetes mellitus. The most prescribed non-steroidal anti-inflammatory drugs were ibuprofen (20.1%), metamizole (14.7%), and diclofenac (11.4%). The prescription of non-steroidal anti-inflammatory drugs was higher in females, in patients aged 51 - 70 years and in the Alentejo region. Non-steroidal anti-inflammatory drugs were prescribed to 70.6% of patients with diabetes mellitus, from which 10.6% were prescribed ≥ 10 packages during the three years. Among patients with diabetes mellitus on angiotensin converting enzyme inhibitors/angiotensin receptor antagonists and with presumed reduction in kidney function, 69.3% were prescribed non-steroidal anti-inflammatory drugs and 11.5% were prescribed ≥ 10 packages during the three years.The level of prescribing of non-steroidal anti-inflammatory drugs to patients with diabetes mellitus is high. The concern of reducing non-steroidal anti-inflammatory drugs prescription to patients already on angiotensin converting enzyme inhibitors/angiotensin receptor antagonists and/or decreased renal function does not seem to exist.In Portugal, the level of prescribing of non-steroidal anti-inflammatory drugs to patients with diabetes mellitus should be reduced, particularly in the subgroups identified with higher prescription and with higher risk of progression to stage 5 chronic kidney disease.Introdução: Portugal apresenta a incidência mais elevada de doença renal crónica estádio 5 na Europa. Especula-se que o elevado consumo de anti-inflamatórios não esteroides possa contribuir para esta incidência. O objetivo do presente estudo foi caracterizar a prescrição de anti-inflamatórios não esteroides a doentes com diabetes mellitus em Portugal. Material e Métodos: Na Base de Dados Nacional de Prescrições do Ministério da Saúde, triénio 2015 - 2017, analisámos a prescrição de anti-inflamatórios não esteroides em doentes com diabetes mellitus, de acordo com a idade, género e região do doente e a especialidade do médico prescritor. Avaliámos a prescrição de anti-inflamatórios não esteroides no total de doentes com diabetes mellitus, em doentes com diminuição presumida da função renal e naqueles com prescrição concomitante de inibidores da enzima de conversão da angiotensina ou antagonistas dos recetores da angiotensina. Resultados: Analisámos 23 320 620 prescrições, correspondendo a 610 157 adultos, dos quais 104 306 doentes com diabetes mellitus. Os anti-inflamatórios não esteroides mais prescritos foram ibuprofeno (20,1%), metamizol (14,7%) e diclofenac (11,4%). A prescrição foi mais frequente nas mulheres, nos doentes com 51 - 70 anos e no Alentejo. Foram prescritos anti-inflamatórios não esteroides a 70,6% dos doentes com diabetes mellitus, dos quais 10,6% receberam prescrições de ≥ 10 embalagens durante os três anos. Dos doentes com diabetes mellitus medicados com inibidores da enzima de conversão da angiotensina ou antagonistas dos receptores da angiotensina e com diminuição presumida da taxa de filtração glomerular, 69,3% receberam prescrição de anti-inflamatórios não esteroides e 11,5% receberam ≥ 10 embalagens durante os três anos. Discussão: A prescrição de anti-inflamatórios não esteroides na diabetes mellitus é elevada. Não parece existir uma preocupação na menor utilização de anti-inflamatórios não esteroides em doentes simultaneamente medicados com inibidores da enzima de conversão da angiotensina ou antagonistas dos recetores da angiotensina e/ou com diminuição da função renal. Conclusão: A prescrição de anti-inflamatórios não esteroides em Portugal a doentes com diabetes mellitus deverá ser reduzida, particularmente nos subgrupos identificados com prescrição mais elevada e com maior risco de progressão para doença renal crónica estádio 5.

Background Thyroid hormones play a central role in cardiovascular homeostasis. Lower free triiodothyronine (FT3) levels have been associated with worse prognosis in several conditions. However, contrary to thyrotropin (TSH) and free thyroxine (FT4), the role of FT3 in morbidity and mortality in the general population remains uncertain. Our objective was to evaluate the association between within the normal range FT3 levels and mortality in the general population. Methods We evaluated 7116 adults in the National Health and Nutrition Examination Survey (NHANES) 2001–2002, 2007–2008, and 2009–2010 cycles with mortality evaluated as of December 2011. Exclusion criteria were: pregnancy; history of thyroid disease; use of thyroid-related drugs; and TSH, FT4, or FT3 level outside the reference range. Results During a median follow-up of 45 months, 357 participants died. In unadjusted analysis, lower FT3 levels were associated with higher all-cause (HR per 0.1 pg/mL increase in FT3: 0.82 [95% confidence interval, 0.78–0.87]), cardiovascular (HR 0.74 [0.66–0.83]), cancer-related (HR 0.88 [0.80–0.97]) and other cause-related mortality (HR 0.83 [0.77–0.90]). After adjustment with Cox proportional hazard models, lower FT3 levels remained significantly associated with higher cardiovascular mortality (HR 0.83 [0.75–0.93]), but not with all-cause (HR 0.97 [0.92–1.02]), cancer-related (HR 1.02 [0.89–1.17]), or other cause-related mortality (HR 1.00 [0.92–1.10]). Conclusions Lower levels of FT3 within the reference range may independently predict higher cardiovascular mortality in the general population.

We read with interest the article by Bress et al. (1) reporting on the effect of intensive versus standard blood pressure treatment according to baseline prediabetes status in a post hoc analysis of the Systolic Blood Pressure Intervention Trial (SPRINT). The authors concluded that the beneficial effects of intensive blood pressure treatment were similar among patients with prediabetes and patients with normoglycemia. We have participated in the SPRINT Data Analysis Challenge (2), and we also analyzed the effects of glycemia status in this population. Whereas we agree with the conclusions presented by the authors, we believe it is also important to assess the effect …

BACKGROUND AND OBJECTIVES: In the Systolic Blood Pressure Intervention Trial (SPRINT), intensive systolic BP treatment (target

We read with interest the paper by Philips et al. [(1)][1] reporting the effect of baseline 10-year cardiovascular disease risk on primary outcome events and all-cause serious adverse events in SPRINT (Systolic Blood Pressure Intervention Trial). The authors concluded that patients with lower

A 61-year-old African-American patient presented to the emergency room with severe back pain. The patient had a history of end-stage renal disease on haemodialysis for 6 years, chronic obstructive lung disease and uncontrolled hypertension. CT scan revealed type B aortic dissection extending from the left subclavian artery to the right renal artery (figures 1⇓–3). There were no signs or symptoms of malperfusion. The patient was medically managed; blood pressure control required four different classes of antihypertensive drugs. It should be noted that the patient had consistently refused antihypertensive treatment previously. …

A previously healthy 29-year-old man was admitted to our hospital, with a 4-day history of fever (39°C), rigours, diaphoresis, fatigue and retro-orbital headache. On examination, he was febrile (37.8°C) and tachycardic (110 bpm). Laboratory work up revealed bicytopenia (white cell count 1.37×10(9)/L, platelets 60×10(9)/L) and an increase in C reactive protein (9 mg/dL). The ECG showed ST segment elevation in V1, V2 and V3 leads. The patient was admitted and investigation was initiated revealing prolonged fever (7 days), pancytopenia, hepatosplenomegaly, hyperferritinemia, hypertriglyceridemia, hypofibrinogenemia, elevated soluble CD25 and hemophagocytosis in bone marrow. Therefore, the patient presented 7 of the 8 diagnostic criteria of hemophagocytic syndrome. Laboratorial investigation for infectious causes was negative, except for IgA and IgG Chlamydophila pneumoniae. ECG re-evaluation on the day of discharge showed no ST segment elevation and no other abnormalities. Genetic testing for known mutations associated with hemophagocytic syndrome and Brugada syndrome did not show any mutations in these genes.

© The Author 2017. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.

An 85-year-old Caucasian woman was admitted to hospital due to acute exacerbation of congestive heart failure, acute-on-chronic kidney disease and cystitis. The patient had stage IV chronic kidney disease, heart failure, permanent atrial fibrillation, chronic obstructive pulmonary disease, arterial hypertension and type 2 diabetes mellitus. Urine culture revealed Escherichia coli sensitive to multiple antibiotics and treatment was initiated with amoxicillin-clavulanate. The patient presented a severe cutaneous reaction with disseminated oedema, erythaema and sudden onset of generalised non-follicular aseptic pustules. Cutaneous lesions were localised at anterior and posterior thoracic regions and also at intertriginous areas of the …