ABSTRACT Introduction: Chronic kidney disease patients have a higher risk of infection and worse clinical outcomes after coronavirus disease. We aimed to assess the prevalence of infection and the humoral response after vaccination in peritoneal dialysis patients. Methods: Three types of vaccines were administered (two doses) with the antibody detection at least six months after. Coronavirus disease 2019 infections, hospital admissions, and deaths were evaluated. Results: From 70 prevalent patients, 45 were included. There was a significant increase in antibody level, with a median of 92 (36, 447) U/mL. Only 4% of patients remained seronegative. History of immunosuppressive therapy was associated with no response (100% vs 60%, p=0.010). There were two infections after the vaccination, without hospital admission. Conclusion: Immunization against coronavirus disease was effective in generating a humoral response in peritoneal dialysis patients. There was also an evident impact of immunosuppressive therapy on vaccine response in peritoneal dialysis patients.

RESUMO Introdução: Receptores de transplante renal são um subgrupo de doentes com maior risco de apresentar formas críticas de infecção por Síndrome Respiratória Aguda Grave pelo Coronavirus-2 (SARS-CoV-2) e piores outcomes devido ao tratamento imunossupressor. Aqui, apresentamos dados de uma coorte de um único centro de receptores de transplante renal com infecção por SARS-CoV-2. Métodos: Num estudo prospectivo, características basais, características clínicas, adaptação da terapêutica antiviral e de imunossupressão foram comparados entre doentes seguidos em ambulatório e doentes hospitalizados durante um período de um ano. Resultados: Foram analisados setenta e sete receptores de transplante renal, incluindo doentes de ambulatório e hospitalizados, com idade média de 57,7 (IIQ 49,7-64,9) anos. Vinte e oito (36,4%) foram tratados em ambulatório enquanto 49 (63,6%) doentes necessitaram de internação hospitalar. Entre os doentes hospitalizados, 18,4% foram admitidos na UTI, 49% apresentaram LRA, e 20,4% morreram. Foram realizados ajustes de imunossupressão em 95,9% dos pacientes hospitalizados, com dose de antimetabólitos ajustada em 83,7%, inibidores de mTOR em 14,3%, inibidores de calcineurina em 12,2%, e terapia com corticosteroides em 81,6%. Conclusão: Entre os pacientes hospitalizados, a optimização da terapêutica imunossupressora incluiu redução ou retirada de antimetabólito e aumento da dose de corticosteroides. A LRA ocorreu em quase metade dos pacientes e a mortalidade em pacientes hospitalizados atingiu 20%, refletindo uma maior gravidade da doença em relação à população em geral.

ABSTRACT Introduction: Kidney transplant recipients are a subgroup of patients at higher risk of critical forms of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection and poor outcomes due to immunosuppression treatment. Herein, we present data from a single center cohort of kidney transplant recipients with SARS-CoV-2 infection. Methods: In a prospective study, baseline characteristics, clinical features, antiviral and immunosuppression management were compared between outpatients and hospitalized patients, during a one-year period. Results: Seventy-seven kidney transplant recipients were analyzed, including outpatients and hospitalized patients, with a median age of 57.7 (IQR 49.7-64.9) years. Twenty-eight (36.4%) were managed as outpatients, while 49 (63.6%) patients required hospital admission. Among hospitalized patients, 18.4% were admitted in ICU, 49% had AKI, and 20.4% died. Immunosuppression adjustments were performed in 95.9% of hospitalized patients, with dose of anti-metabolites adjusted in 83.7%, mTOR inhibitors in 14.3%, calcineurin inhibitors in 12.2%, and corticosteroid therapy in 81.6%. Conclusion: Among hospitalized patients, immunosuppression management included reduction or withdrawal of anti-metabolite and increase of corticosteroid dose. AKI occurred in almost half of patients and mortality in hospitalized patients reached 20%, reflecting greater disease severity than the general population.

Chronic kidney disease (CKD) is increasing worldwide and studies estimate that around 6% of women of childbearing age suffer from kidney disease. Preconception counselling of women with CKD and their management during pregnancy requires a multidisciplinary team, with both nephrologists and obstetricians experienced in advising and taking care of women across the CKD spectrum, including dialysis patients and women with a kidney transplant. Here, the authors describe a model of a Nephro-Obstetric outpatient clinic, created in 2011, detailing their current clinical experience in the management of this complex population of women.

Purpose: The aim of this study is to characterize a Portuguese Intensive Care Unit experience in therapeutic plasma exchange in critically ill patients. Methods: We performed a retrospective analysis of the patients treated with therapeutic plasma exchange between 2000 and 2019. Data on patient characteristics, therapeutic plasma exchange prescription, adjuvant therapy used, adverse events and outcome under treatment were collected. Results: A total of 101 therapeutic plasma exchange procedures in 20 patients were studied. Mean number of therapeutic plasma exchange sessions per patient was 5.1±1.3. The most frequent indications to begin this treatment were myasthenia gravis (25.0%) and anti-neutrophil-cytoplasmic antibody-associated vasculitis (15.0%). There were 45.5% adverse events and the most frequent was hypotension (15.2%). 98% of the complications were mild-to-moderate. The outcome was favorable in 60.0% of patients. Conclusion: Therapeutic plasma exchange is an effective and safe therapy in many diseases that had high morbidity and mortality prior to the use of this technique.

Resumo Fundamento: Pacientes com doença valvar aórtica frequentemente apresentam doença renal crônica (DRC). Diminuição da perfusão renal como consequência da redução do débito cardíaco pode contribuir para a disfunção renal neste cenário. Objetivo: Dado o potencial de reversibilidade da hipoperfusão renal após o reparo valvar, este estudo teve o objetivo de analisar o impacto do implante percutâneo de válvula aórtica (TAVI - transcatheter aortic valve implantation) na função renal. Métodos: Foi realizada uma análise retrospectiva de 233 pacientes consecutivos submetidos ao TAVI em um único centro, entre novembro de 2008 e maio de 2016. Três grupos foram avaliados de acordo com a taxa de filtração glomerular estimada (TFGe) basal (mL/min/1,73 m2): Grupo 1 com TFGe ≥ 60; Grupo 2 com 30 ≤ TFGe < 60; e Grupo 3 com TFGe < 30. O TFGe foi analisado nestes três grupos um mês e um ano após o TAVI e calculado usando a fórmula do Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI). Resultados: Os pacientes do Grupo 1 tiveram um declínio progressivo da TFGe um ano após o procedimento TAVI (p < 0,001 vs. pré-TAVI). Nos pacientes do Grupo 2, a média da TFGe aumentou um mês depois do TAVI e continuou crescendo depois de um ano (p = 0,001 vs. pré-TAVI). O mesmo ocorreu no Grupo 3, com a média da TFGe subindo de 24,4 ± 5,1 mL/min/1,73 m2 antes do TAVI para 38,4 ± 18,8 mL/min/1,73 m2 um ano após o TAVI (p = 0,012). Conclusões: Em pacientes com DRC moderada a grave, a função renal melhorou um ano após o procedimento TAVI. Este resultado é provavelmente devido à melhora da perfusão renal pós-procedimento. Acredita-se que, ao avaliar pacientes que possam precisar de TAVI, este ‘efeito de reversibilidade da DRC’ deva ser considerado.

Abstract Background: Chronic kidney disease (CKD) is frequently present in patients with aortic valve disease. Decreased kidney perfusion as a consequence of reduced cardiac output may contribute to renal dysfunction in this setting. Objective: Given the potential reversibility of kidney hypoperfusion after valve repair, this study aimed to analyze the impact of percutaneous transcatheter aortic valve implantation (TAVI) on kidney function. Methods: We performed a retrospective analysis of 233 consecutive patients who underwent TAVI in a single center between November 2008 and May 2016. We assessed three groups according to their baseline estimated glomerular filtration rate (eGFR) (mL/min/1.73 m2): Group 1 with eGFR ≥ 60; Group 2 with 30 ≤ eGFR < 60; and Group 3 with eGFR < 30. We analyzed the eGFR one month and one year after TAVI in these three groups, using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula to calculate it. Results: Patients from Group 1 had a progressive decline in eGFR one year after the TAVI procedure (p < 0.001 vs. pre-TAVI). In Group 2 patients, the mean eGFR increased one month after TAVI and continued to grow after one year (p = 0.001 vs. pre-TAVI). The same occurred in Group 3, with the mean eGFR increasing from 24.4 ± 5.1 mL/min/1.73 m2 before TAVI to 38.4 ± 18.8 mL/min/1.73 m2 one year after TAVI (p = 0.012). Conclusions: For patients with moderate-to-severe CKD, kidney function improved one year after the TAVI procedure. This outcome is probably due to better kidney perfusion post-procedure. We believe that when evaluating patients that might need TAVI, this ‘reversibility of CKD effect’ should be considered.

Severe hypertriglyceridemia is defined as a serum triglyceride level >885mg/dl. It is an uncommon condition associated with serious complications, mainly acute pancreatitis. Treatment includes lifestyle changes, medical therapy and, more recently, extracorporeal apheresis techniques. Herein, we report a case of severe hypertriglyceridemia managed with therapeutic plasma exchange. Our patient presented with severe upper abdominal pain. Bloodwork showed extremely severe hypertriglyceridemia (14871mg/dl) and hypercholesterolemia (1536mg/dl) with only slight elevation of amylase and lipase and no echographic signs of acute pancreatitis. Two sessions of therapeutic plasma exchange were performed, with a mean 3L of plasma treated per session. The triglyceride levels dropped to 2325mg/dl after the first session and to 1207mg/dl after the second. Medical therapy was started, and the patient was discharged a week later. After 36 months of follow-up she remains stable, with triglyceride levels 427mg/dl. In this case therapeutic plasma exchange was an effective and well tolerated treatment for severe hypertriglyceridemia