Simultaneous kidney pancreas transplantation, if feasible, is the treatment of choice for the management of end-stage renal disease in patients with type 1 diabetes. This intervention can offer glycemic control and might also stabilize or even reverse some of the metabolic complications of diabetes. Chronic kidney disease has become a critical problem in orthotopic liver transplantation due to multiple risk factors, including post-transplant diabetes mellitus and immunosuppression. This has a major impact on graft and patient survival. In this paper we present the case of a 42-year-old man submitted to a simultaneous pancreas kidney transplant after a successful liver transplantation 18 years earlier. The surgical procedure was uneventful, and the patient was discharged 18 days after admission. The case findings support that simultaneous pancreas and kidney transplantation is an effective method for the treatment of chronic kidney disease in patients with diabetes and a previous liver transplant.

Antibody mediated rejection (ABMR) is a major cause of kidney graft loss. The ideal treatment remains unknown, is not standardized and there is little evidence to support the use of any specific therapy. This paper aims to reflect on the current state of this challenging diagnosis, either active or chronic active ABMR, and its treatment options. The current treatments encompass plasma exchange, steroids, intravenous immunoglobulin, rituximab, bortezomib, eculizumab, C1 inhibitors, IL 6 inhibitors and IgG-degrading enzyme of Streptococcus pyogenes among others. We will try to analyze the main studies that sustain or reject the current and future use of these techniques and drugs.

Typhlitis is a clinical entity rare in adults, reported in immunosuppressed patients. It is a life-threatening condition that occurs in neutropenic patients due to compromised integrity of the bowel wall and its exact pathogenesis is not completely understood. We report a 35-year-old man with a post deceased donor renal and pancreas transplantation status who presented fever and febrile neutropenia. Three days after admission he presented hematochezia with a hemoglobin drop. Colonoscopy revealed "ileum mucosa with multiforme ulcers" and since no other etiology was found, typhlitis was considered. He gradually improved with support treatment and was able to be managed non-operatively. To our knowledge, there are only six other reports of typhlitis in kidney transplant recipients.

RESUMO Introdução: Um débito de sangue de acesso arteriovenoso (AV) (Qa) de 400 mL/min é geralmente suficiente para uma hemodiálise (HD) eficaz, mas alguns acessos continuam se desenvolvendo e se tornam acessos de alto débito (AAD). Alguns autores postularam que um AAD poderia desviar uma porção significativa do sangue dialisado do débito cardíaco, o que poderia diminuir a eficiência da HD e levar à sobrecarga de volume. Objetivo: O objetivo do nosso estudo foi avaliar se o AAD está associado à redução da eficiência da HD e/ou à sobrecarga de volume em pacientes prevalentes em HD. Métodos: Foi realizado um estudo retrospectivo de 1 ano, e avaliada a eficiência da HD pela porcentagem de sessões em que o Kt/V > 1,4 e a sobrecarga de volume avaliada pela bioimpedância. Resultados: O estudo incluiu 304 pacientes prevalentes em HD, com média de idade de 67,5 anos; 62,5% eram do sexo masculino; 36,2% eram diabéticos, com uma mediana de tempo em HD de 48 meses. Dezesseis por cento dos pacientes apresentavam AAD (definida como Qa > 2 L/min). Na análise multivariada, os pacientes com AAD apresentaram maior risco de sobrecarga de volume (OR = 2,67; IC95% = 1,06-6,71) e sobrecarga severa de volume (OR = 4,06; IC95% = 1,01-16,39) e atingiram o peso seco com menor frequência (OR = 0,37, IC 95% = 0,14-0,94). No entanto, o AAD não foi associado uma menor razão Kt/V. Conclusão: Nossos resultados sugerem que pacientes com AAD apresentam maior risco de sobrecarga de volume. No entanto, ao contrário do que foi postulado, o AAD não foi associado à diálise menos eficiente, medida pelo Kt/V. Ensaios clínicos randomizados são necessários para esclarecer essas questões.

ABSTRACT Introduction: An arteriovenous (AV) access flow (Qa) of 400 mL/min is usually sufficient for an effective hemodialysis (HD), but some accesses continue developing and become high flow accesses (HFA). Some authors postulated that an HFA might shift a significant portion of dialyzed blood from the cardiac output, which could decrease HD efficiency and lead to volume overload. Objective: The aim of our study was to evaluate if HFA is associated with reduced HD efficiency and/or volume overload in prevalent HD patients. Methods: We performed a 1-year retrospective study and assessed HD efficiency by the percentage of sessions in which the Kt/V > 1.4 and volume overload by bioimpedance spectroscopy. Results: The study included 304 prevalent HD patients with a mean age of 67.5 years; 62.5% were males, 36.2% were diabetics, with a median HD vintage of 48 months. Sixteen percent of the patients had a HFA (defined as Qa > 2 L/min). In multivariate analysis, patients with HFA presented higher risk of volume overload (OR = 2.67, 95%CI = 1.06-6.71) and severe volume overload (OR = 4.06, 95%CI = 1.01-16.39) and attained dry weight less frequently (OR = 0.37, 95%CI = 0.14-0.94). However, HFA was not associated with lower Kt/V. Conclusion: Our results suggest that patients with HFA have higher risk of volume overload. However, contrarily to what has been postulated, HFA was not associated with less efficient dialysis, measured by Kt/V. Randomized controlled trials are needed to clarify these questions.

Myeloma-associated renal disorders are rare events among renal transplants and can occur as recurrent or de novo disease. We describe an unusual case of renal allograft dysfunction due to myeloma cast nephropathy occurring 19 years after having received a renal transplant in a patient with no prior history of multiple myeloma or monoclonal gammopathy preceding transplantation. Our patient was treated with five cycles of chemotheraphy (bortezomib, melphalan and steroids), which resulted in short-term improvement in allograft dysfunction and complete haematological remission. The longer patient and graft survival after renal transplantation make post-transplant lymphoproliferative disease more frequent. Multiple myeloma after kidney transplant is rare and an elevated index of suspicion is necessary to make a timely diagnosis of this serious disease. Further work is needed to identify the best treatment options for these patients

A doença renal crónica pode conduzir a distúrbios metabólicos como hiperfosfatemia, aumento da secre- ção do “fibroblast growth factor- 23”, e deficiência de vitamina D, que por sua vez, podem conduzir a um aumento dos níveis plasmáticos da paratormona, e a uma diminuição dos níveis plasmáticos de cálcio. Consequentemente, a doença renal crónica pode contribuir para o desenvolvimento de hiperparatiroidismo secundário, e de anomalias no metabolismo mineral ósseo. A transplantação renal é a opção que proporciona a maior longevidade e qualidade de vida, a doentes com doença renal crónica terminal. A deficiência de vitamina D tem sido associada a doença cardiovascular, que é a causa principal de mortalidade nos transplantados renais. Logo, o diagnóstico desta deficiência poderá ser crucial para tentar minimizar esta mortalidade, uma vez que esta deficiência de vitamina D pode ser corrigida terapeuticamente. O calcitriol tem como indicação terapêutica o tratamento da deficiência de vitamina D, tanto em doentes com doença renal crónica, como em doentes transplantados renais. No entanto, este fármaco pode aumentar os níveis plasmáticos de cálcio e de fósforo, conduzindo a potenciais calcificações vasculares, que têm sido associadas a mortalidade cardiovascular. Os ativadores seletivos dos recetores da vitamina D têm como indicação terapêutica o tratamento da deficiência de vitamina D na doença renal crónica. A vantagem destes fármacos é que têm sido associados a aumentos inferiores dos níveis plasmáticos de cálcio e fósforo. Estes fármacos têm ainda efeitos adicionais que podem minimizar a morbilidade e a mortalidade, principalmente devido ao seu potencial para reduzir eventos cardiovasculares. Neste artigo apresentamos uma revisão de literatura sobre a fisiologia da vitamina D, sobre as consequências da sua deficiência na doença renal crónica e em doentes transplantados renais, e sobre o diagnóstico e tratamento desta deficiência. Finalmente, discutimos os resultados de estudos recentes, sobre a segurança e eficácia dos ativadores seletivos dos recetores da vitamina D em doentes transplantados renais

Severe chronic kidney disease may lead to disturbances, such as hyperphosphatemia, increased secretion of fibroblast growth factor-23 (FGF-23) and vitamin D deficiency. These may increase plasmatic levels of parathyroid hormone, and decrease plasmatic levels of calcium. Altogether, these may contribute to the development of secondary hyperparathyroidism, and to abnormalities in mineral metabolism. Kidney transplantation is the best option to improve longevity and quality of life in end-stage chronic kidney disease patients. Vitamin D deficiency has been associated with cardiovascular disease, which is the leading cause of death in chronic kidney disease. Therefore, diagnosing this deficiency may be pivotal for minimizing mortality in chronic kidney disease, because pharmacological treatments for this deficiency may be prescribed. Calcitriol is indicated for the treatment of vitamin D deficiency, both in chronic kidney disease and in kidney transplanted patients. However, calcitriol may increase the plasmatic levels of calcium and phosphorous, which can lead to vascular calcifications, that have been associated with cardiovascular mortality. Selective vitamin D receptor activators are indicated for the treatment of vitamin D deficiency in chronic kidney disease. These have the advantage of being associated with lower increases of plasmatic levels of calcium and phosphorous. These drugs also seem to have additional effects that may minimise patient morbidity and mortality, especially due to potentially reducing cardiovascular events. Unfortunately, there are few studies about the use of these drugs in kidney transplanted patients. Here we present a review about the physiology of vitamin D, the consequences of its deficiency in chronic kidney disease and in kidney transplanted patients, and about the diagnosis and treatment of this deficiency. Finally, we discuss the new line of research about the efficacy and safety of selective vitamin D receptor activators in kidney transplanted patients

Os esquemas de diálise longa, com taxas de ultrafiltração/hora mais baixas, têm sido associados a menor mortalidade, na maioria dos estudos. Neste contexto, a diálise longa noturna surgiu como uma modalidade de diálise alternativa e atrativa. A diálise longa noturna tem sido associada a maior eficácia dialítica, melhor controlo tensional, com diminuição das necessidades medicamentosas e melhor qualidade de vida. O nosso centro iniciou recentemente um programa de diálise longa noturna cujos resultados nos propusemos analisar num estudo prospetivo e observacional. Com este objectivo, avaliámos a evolução de variáveis clínicas e analíticas em 2 semestres consecutivos, antes e após a transição de hemodiafiltração para diálise longa noturna. Seis meses após a transição, verificámos uma melhoria da eficiência dialítica (redução de ureia pré-diálise (129.74 ± 28.7 vs. 114.53±23.94 mg/dl, p=0.01) e subida de Kt/V (1.75 vs. 2.09 ± 0.39, p= 0.005)), do controlo da hiperfosfatemia (5.05 ± 0.9 vs. 4.23 ± 0.93 mg/dl; p = 0.01) e da anemia, com significativa redução do consumo de darbepoetina alfa (38.5 ± 24.18 vs. 30.83 ± 22.54 μg/semana; p = 0.04) e de ferro endovenoso (189.33 ± 117 vs. 116 ± 67 mg/mês; p = 0.04), bem como uma excelente correção do estado de híper-hidratação (avaliado pelo monitor de “BCM-Body composition monitor”: 10.2% ± 8.63 vs. 4.6% ± 7.2; p = 0.01), reflexo do melhor estado nutricional dos doentes. A estes benefícios acresceuse a perceção de melhoria da qualidade de vida dos doentes. O nosso estudo vem juntar-se à lista de trabalhos cujos resultados favorecem a diálise longa noturna em relação à hemodiálise convencional, mas são necessários estudos randomizados para validar estes resultados.

The institution of intensified dialysis regimens (as long treatment time, with reduced ultrafiltration per hour) has been associated with decreased morbidity and mortality in patients with end-stage chronic kidney disease. The performance of the haemodialysis session during the night interval emerged as logical, since it is an “idle” period, and has been associated with better small molecule dialysis, better blood pressure control, reduced medication requirements and improved quality of life. Recently, our centre initiated a long nocturnal dialysis programme and a prospective observational analysis was designed to evaluate the results of this approach. Mean values of clinical and laboratory variables were compared in 2 consecutive semesters: prior and after transition from haemodiafiltration to long nocturnal dialysis. After 6 months of switching, there was an increase in dialysis efficiency (reduction in pre-dialysis urea (129.74 ± 28.7 vs. 114.53 ± 23.94 mg/dl, p = 0.01) and an increase in Kt/V (1.75 ± 0.37 vs. 2.09 ± 0.39, p = 0.005)), improved hyperphosphatemia control (5.05 ± 0.9 vs. 4.23 ± 0.93 mg/dl; p = 0.01) and anaemia control, with a significant reduction in the use of darbepoetin alfa (38.5 ± 24.18 vs. 30.83 ± 22.54 μg/week; p = 0.04) and of intravenous iron (189.33 ± 117 vs. 116 ± 67 mg/month; p = 0.04) and a much better correction of overhydration (evaluated by the “BCM-Body composition monitor”: 10.2% ± 8.63 vs. 4.6% ± 7.2; p = 0.01), reflecting the patients’ overall better nutritional status. These excellent results were amplified by the patients’ perception of improvement in their quality of life. Our findings are consistent with the studies that favour long nocturnal dialysis over conventional regimens, but randomized controlled trials are needed to validate these findings.

Background: Protein-energy wasting (PEW), associated with inflammation and overhydration, is common in haemodialysis (HD) patients and is associated with high morbidity and mortality. Objective: Assess the relationship between nutritional status, markers of inflammation and body composition through bioimpedance spectroscopy (BIS) in HD patients. Methods: This observational, cross-sectional, single centre study, carried out in an HD centre in Forte da Casa (Portugal), involved 75 patients on an HD programme. In all participating patients, the following laboratory tests were conducted: haemoglobin, albumin, C-reactive protein (CRP) and 25-hydroxyvitamin D3 [25(OH)D3]. The body mass index of all patients was calculated and a modified version of subjective global assessment (SGA) was produced for patients on dialysis. Intracellular water (ICW) and extracellular water (ECW) were measured by BIS (Body Composition Monitor®, Fresenius Medical Care®) after the HD session. In statistical analysis, Spearman´s correlation was used for the univariate analysis and linear regression for the multivariate analysis (SPSS 14.0). A P value of <.05 was considered statistically significant. Results: PEW, inversely assessed through the ICW/body weight (BW) ratio, was positively related to age (p<.001), presence of diabetes (p=.004), BMI (p=.01) and CRP (P=.008) and negatively related to albumin (p=.006) and 25(OH)D3 (p=.007). Overhydration, assessed directly through the ECW/BW ratio, was positively related with CRP (p=.009) and SGA (p=.03), and negatively with 25(OH)D3 (p=.006) and BMI (p=.01). In multivariate analysis, PEW was associated with older age (p<.001), the presence of diabetes (p=.003), lower 25(OH)D3 (p=.008), higher CRP (p=.001) and lower albumin levels (p=.004). Overhydration was associated with higher CRP (p=.001) and lower levels of 25(OH)D3 (p=.003). Conclusions: Taking these results into account, the ICW/BW and ECW/BW ratios, assessed with BIS, have proven to be good markers of the nutritional and inflammatory status of HD patients. BIS may be a useful tool for regularly assessing the nutritional and hydration status in these patients and may allow nutritional advice to be improved and adjusted.

Antecedentes: El desgaste proteico-energético (DPE), asociado a inflamación e hiperhidratación, es común en pacientes en hemodiálisis (HD) y se asocia a mayor morbilidad y mortalidad. Objetivo: Evaluar la relación entre el estado nutricional, los marcadores inflamatorios y la composición corporal a través de bioimpedancia espectroscópica (BIS) en pacientes en HD. Métodos: En este estudio observacional, transversal, unicéntrico, realizado en un centro de HD en Forte da Casa (Portugal), participaron 75 pacientes en programa de HD. En todos los participantes se hicieron las siguientes determinaciones analíticas: hemoglobina, albúmina, proteína C reactiva (PCR) y 25-hidroxivitamina D3 [25(OH)D3]. Se calculó el índice de masa corporal (IMC) de todos los pacientes y se aplicó una versión modificada de la valoración global subjetiva (VGS) para pacientes en diálisis. El agua intracelular (AIC) y extracelular (AEC) se midió con BIS (Body Composition Monitor®, Fresenius Medical Care®) después de la sesión de HD. En el análisis estadístico se utilizó la correlación de Spearman para el análisis univariante y la regresión lineal para el análisis multivariante (SPSS 14.0). Una p < 0,05 se consideró estadísticamente significativa. Resultados: El DPE, evaluado inversamente a través de la relación AIC/peso corporal (PC), se relacionó positivamente con la edad (p < 0,001), la presencia de diabetes (p = 0,004), el IMC (p = 0,01) y la PCR (p = 0,008) y negativamente con la albúmina (p = 0,006) y la 25(OH)D3 (p = 0,007). La hiperhidratación, evaluada directamente a través de la relación AEC/PC, se relacionó positivamente con la PCR (p = 0,009) y con la VGS (p = 0,03), y negativamente con la 25(OH)D3 (p = 0,006) y el IMC (p = 0,01). En el análisis multivariante, el DPE se asoció a edad más elevada (p < 0,001), presencia de diabetes (p = 0,003), 25(OH)D3 más baja (p = 0,008), PCR más elevada (p = 0,001) y niveles de albúmina más bajos (p = 0,004). La hiperhidratación se asoció a PCR más elevada (p = 0,001) y niveles de 25(OH)D3 más bajos (p = 0,003). Conclusiones: Teniendo en cuenta estos resultados, las relaciones AIC/PC y AEC/PC, evaluadas con BIS, han demostrado ser buenos marcadores del estado nutricional e inflamatorio de pacientes en programa de HD. La BIS puede ser una herramienta útil para evaluar regularmente el estado nutricional y de hidratación en estos pacientes y puede permitir mejorar y adecuar el asesoramiento nutricional.