Resumo 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.

Abstract 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.

Resumo 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.

Abstract 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.

The evaluation of chronic kidney disease-mineral and bone disorder (CKD-MBD) is based on clinical, laboratory, radiology and histological data. However, these data may not always be entirely concordant, leading to significant doubt over therapeutic options. We present a challenging CKD-MBD case report. A 26-year-old female patient presented a past medical history of systemic erythematosus lupus and end-stage renal disease. She had been on hemodialysis and transited to peritoneal dialysis due to multiple vascular access failure. Medication included calcium carbonate, cholecalciferol, calcitriol, and cinacalcet but adherence to medication was low, leading to PTH values often higher than 1000 pg/mL. She presented right knee pain for two months. Radiology exams revealed iliac, femoral and tibial osteolytic lesions. A bone biopsy was performed, detecting disperse multinucleated giant cells compatible with brown tumors. However, poor therapeutic adherence did not allow persistent control of hyperparathyroidism, with PTH levels often >1000 pg/mL, and parathyroidectomy was considered. A tetracycline-labeled bone biopsy showed high turnover bone disease in the past, evolving to low-bone turnover/adynamic bone disease. This led to the decision of optimizing medical treatment and avoiding parathyroidectomy. Significant clinical improvement was observed with knee pain resolution and transient reduction of PTH to stage 5 chronic kidney disease reference levels. Four years later an imagiological re-evaluation was performed, revealing bilateral tibial, femoral and iliac enlarged bone lesions, and bone scintigraphy confirmed hypermetabolic lesions. She was then submitted to subtotal parathyroidectomy and subsequently to deceased-donor renal transplantation. This case report shows the importance of closely following CKD-MBD patients, even in asymptomatic patients. Treatment decision should not solely include bone histology criteria. Repeated evaluations at different time points of clinical, laboratory, and radiology data might be particularly useful

Encapsulating peritoneal sclerosis (EPS) is an uncommon but serious complication of peritoneal dialysis (PD). We present a case report of EPS and a brief description of the disease. A previously stable 47-year-old male patient on hemodialysis (HD) presented to the hospital with weight loss, fever, anorexia, increased abdominal volume, anemia, increased inflammatory markers, septated hemoperitoneum, and peritoneal thickening on imaging. The patient had previously been on PD for 8 years and had 7 peritonitis episodes caused by different microorganisms. Note that the patient had a previous history of multiple vascular access failure and presented poor habitational conditions and socioeconomic status. He had been transferred from PD to HD five months earlier due to hypervolemia. A diagnosis of EPS was considered. Treatment was initiated with regular peritoneal lavage, nutritional support, oral prednisolone, and tamoxifen. The patient presented complete resolution of the symptoms and regularization of inflammatory markers. Two months later he presented to the emergency room with intestinal obstruction, and surgical enterolysis with debridement of the thick cocoon of fibrous tissue was performed. However, the patient presented several complications and died two months after admission. In conclusion, a high index of clinical suspicion of EPS in susceptible patients is necessary as the disease is infrequent and may be fatal. A greater awareness of EPS may lead to earlier or increased diagnosis rates in milder cases. This case report highlights the importance of implementing preventive measures in patients with several risk factors for EPS and considering an EPS diagnosis in a patient that is no longer on PD

The increasing prevalence of end-stage chronic kidney disease associated with advances in treatment is expected to lead to improved survival rates of chronic haemodialysis patients in Portugal. Establishing and maintaining vascular access patency is becoming a challenging issue in these patients. We present a case report of a multiple vascular access failure patient to whom a novel vascular access device was implanted which allowed successful haemodialysis, despite the presence of central venous stenosis and/or occlusion. To our knowledge the present case report describes the first utilization of Hemodialysis Reliable Outflow (HeRO) Graft device in Portugal. We present the case as well as a brief description of the device and available literature. This case report also underlines the importance of adopting a multidisciplinary approach in order to overcome complex and life-threatening clinical challenges