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.

ABSTRACT Introduction: The severe acute respiratory syndrome coronavirus 2 pandemic caused a negative impact on transplantation worldwide. One of the complexities is the management of the immunosuppression and anti-viral medication in transplant recipients. Herein we describe our experience managing five patients with coronavirus disease 2019 (COVID-19) immediately after kidney transplant. Description: we describe a series of five transplant recipients. Two were submitted to a low immunological risk induction immunosuppression: one developed severe disease, the other developed critical disease. The remaining three were submitted to a high immunologic risk immunosuppression: one developed mild disease, but approximately two months after diagnosis developed moderate COVID-19; another developed severe COVID-19; the remaining patient developed critical illness and perished. Both patients with critical COVID-19 developed bacterial and fungal superinfections in the Intensive Care Unit. All eligible patients were submitted to remdesivir and dexamethasone. The anti-metabolite was reduced or suspended. Despite worsening kidney function during the acute phase, kidney replacement therapy was only needed in one patient and the average serum creatinine at the time of discharge was lower that the pre-COVID-19 nadir. Discussion: There is still no definitive answer on whether solid organ transplant recipients carry a higher risk for morbimortality. Risk factors for the general population can also affect their outcome. The prolonged viral shedding in recipients may explain the irregular evolution of the patient who developed COVID-19 months after the initial diagnosis. The reduction of immunosuppression can be problematic in early post-transplant, but no apparent signs of rejection were noted. Literature addressing this specific context is scarce and studies are needed to clarify the optimal management of these patients.

New data on vitamin D has emerged in the last fifteen years and continues to expand practically every day. It's almost impossible to describe its full actions in a short article. In this review only a few aspects of this family of compounds are described, namely its endocrine pathway, and a few of its pleiotropic effects. Some of the known consequences of vitamin D deficiency are listed and special attention is given to its metabolism and the best way to supplement it, according to the author

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.

C3 glomerulonephritis is a rare disease defined by deposits of C3 on immunofluorescence due to dysregulation of the alternative pathway of the complement cascade. We present a case of a female patient that presented with nephrotic syndrome at the age of 18 due to C3 glomerulonephritis and progressed to end-stage renal disease after 9 years. She lost the first kidney graft on the third day after transplantation due to vascular thrombosis. A second kidney transplant was performed when the patient was 30 years old. C3 glomerulonephritis recurred on the kidney graft and the patient returned to dialysis 10 years after the transplant. Study of the alternative complement pathway revealed anti-factor H antibodies. She is currently on evaluation for a third kidney transplant and there is no consensus on the best treatment strategy. We present the literature available for treatment of C3 glomerulonephritis and the therapeutic options for this patient

Introduction: Kidney transplant (KT) recipients are highly susceptible to urinary tract infections (UTIs). Few data are available regarding the effects of cranberry products in KT recipients. Subjects and methods: This was a randomized double-blind study comparing daily treatment with a cranberry capsule versus a placebo capsule for 6 months. The study protocol was conducted in accordance with the Helsinki Declaration and was approved by the local ethics committee. The study group comprised women undergoing KT for over 1 year, and the exclusion criteria included simultaneous antibiotic UTI prophylaxis. The primary endpoint was UTI occurrence, and the secondary endpoints were the time to first UTI, hospitalization, antibiotic resistance, graft function, immunosuppressive dose changes, and side effects. Results: 55 KT women at a single centre were included as follows: 25 were randomized to the cranberry group, and 30 were assigned to the placebo group. During the study period, 16.4% of the participants presented with a UTI. A diagnosis of UTI within the previous year and KT duration, but not cranberry use (p=0.95) were independent predictors of UTI. Discussion: Cranberry capsules appear to be safe in KT women; however, no clinical efficacy of UTI prophylaxis was demonstrated in this well-designed but underpowered study. Further multicentric and longer trial should be performed to determine cranberry clinical efficacy

Introducão: A doença renal crónica provoca a diminuição da fertilidade. Com a transplantação renal a ferti- lidade é recuperada em poucos meses. Objetivo: Analisar a viabilidade da gravidez no transplante renal e o seu impacto sobre a função renal, as complicações na mulher e no recém-nascido. Métodos: Estudo retro- spectivo das gravidezes ocorridas em transplantadas renais entre 1985 e 2014 numa Unidade de Transplantação, com um follow-up de 12 meses pós gravidez. Resultados: Foram incluídas 18 gravidezes (1 gravidez gemelar) em 13 transplantadas renais com uma média de idades de 31 anos. Destas, 12 gravidezes progrediram, 5 resultaram em aborto espontâneo e 1 em aborto induzido. Apenas uma gravidez se complicou por diabetes gestacional. Ocorreram dois nados-mortos (gravidez gemelar). O peso médio dos 11 recém-nascidos foi de 2,6 kg. Verificou-se uma diminuição significativa da taxa de filtração glomerular estimada aos 3 meses pós parto [p < 0.05], mas 1 ano pós parto a tendência deixou de ser significativa [p> 0.05]. Relativamente à proteinuria, o aumento significativo aos 3 meses pós parto manteve-se aos 12 meses [p < 0.05]. No 3o trimestre verificou-se um aumento significativo da tensão arterial [p < 0.05], que não se manteve aos 12 meses pós parto [p > 0.05]. Nos doentes sob ciclosporina verificou-se uma diminuição dos níveis séricos [p < 0.05] ao longo da gravidez. Não se detetou nenhuma rejeição assim como falência do enxerto durante a gravidez ou no follow-up pós parto. Conclusão: Embora a amostra seja limitada, o número de abortos espontâneos foi superior ao da população geral (24% versus 8 a 20%). O aumento significativo da proteinuria mantido após um ano sugere o aumento do risco de disfunção do enxerto a longo prazo. A diminuição dos níveis séricos de ciclosporina ao longo da gravidez implica uma vigilância mais apertada deste parâmetro neste período

Background: Chronic kidney disease causes decreased fertility. With kidney transplantation, fertility is restored within a few months. Objective: To analyse the feasibility of pregnancy with renal transplantation and its impact on renal function, complications in women and newborns. Methods: Retrospective study of pregnancies that occurred in kidney transplant recipients between 1985 and 2014 in one Transplantation Unit, with a follow-up of 12 months post-partum. Results: Eighteen pregnancies were included (one twin pregnancy) in 13 kidney transplant recipients with an average age of 31 years. Of these, 12 pregnancies progressed, five resulted in miscarriage and one in abortion. Only one pregnancy was complicated by gestational diabetes. There were two stillbirths (twin pregnancy). The average weight of 11 newborns was 2.6 kilograms. There was a significant decrease of estimated glomerular filtration rate at 3 months post-partum [p < 0.05], but a year after delivery, the tendency was not maintained [p > 0.05]. Regarding proteinuria, the significant rise at 3 months was maintained until one year [p <0.05]. A significant increase in blood pressure was observed only on the 3rd trimester [p < 0.05], which did not maintain a year after delivery [p > 0.05]. In patients taking cyclosporine, a decrease in serum levels [p < 0.05] was found throughout the pregnancy. No rejection was detected, as well as graft failure during pregnancy or post-partum follow-up. Conclusion: Although the sample is limited, the number of miscarriages was higher than in the general population (24% versus 8 to 20%). The significant increase of the proteinuria throughout a year suggests a long-term increased risk of graft dysfunction. The decrease in serum cyclosporine levels during pregnancy implies a tighter monitoring of this parameter throughout this period

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.

Uma transplantada renal de 50 anos, pós menopáusica, com dor óssea, osteoporose, hipercalcémia persistente e níveis elevados de paratormona, apesar de uma razoável função do enxerto renal, foi tratada com bifosfonatos e cinacalcet com início 5 e 6 meses, respectivamente, após a transplantação renal. Verificouse melhoria da densidade óssea medida por DEXA. Foi realizada uma biópsia óssea que revelou um resultado inesperado e preocupante. A doença óssea após a transplantação renal é diferente da DMO-DRC clássica e deve ser gerida de forma distinta. Nalguns casos, como o ilustrado na presente apresentação, justifica-se o diagnóstico invasivo através do recurso à realização de uma biópsia óssea, como é proposto nas orientações da KDIGO.

A 50-year-old post-menopausal recipient of a kidney allograft with bone pain, osteoporosis, persistent hypercalcaemia and elevated parathormone (PTH) levels, despite a satisfactory graft function, was treated with bisphosphonates and cinacalcet starting, respectively, 5 and 6 months after renal transplantation (RT). Sixteen months after treatment, there was improvement of bone mineral density (BMD) measured by dualenergy X-ray absorptiometry (DEXA). A bone biopsy was taken, unveiling a surprising and worrisome result. Post-RT bone disease is different from classic CKD-MBD and should be managed distinctly, including, in some difficult cases, an invasive evaluation through the performance of a bone biopsy, as suggested in the KDIGO guidelines.

Introdução: Os mTOR mostraram-se eficazes na imunossupressão de manutenção em relação à sobrevida do enxerto, mas o seu impacto na sobrevida do doente só recentemente foi avaliado. Neste estudo analisámos todos os doentes transplantados renais na nossa unidade desde 2006/01/01 até 2011/12/31 no que respeita à falência do enxerto e à mortalidade comparando os doentes que foram convertidos para mTOR com os que permaneceram sob inibidor da calcineurina (CNI).População e métodos: Foram avaliados 425 doentes (idade média de 46 ± 13 anos, 60,7% do sexo masculino, 10,1%, diabéticos com tempo médio de seguimento de 44 meses). Durante este período, 123 doentes foram convertidos para mTOR: 8, incluídos no protocolo de um estudo, 13 por neoplasia e 102 por evidência de disfunção crônica do enxerto. Os restantes doentes foram mantidos sob CNI. A sobrevida do enxerto e do doentes foram comparados por Kaplan-Meier e p<0,05 foi considerado significativo.Resultados: Durante o tempo de seguimento, 10 doentes morreram e 28 perderam o enxerto. As características basais foram semelhantes para ambos os grupos, com excepção da idade (os doentes convertidos eram mais velhos, p = 0,012), sexo (masculino mais frequente no grupo mTOR grupo, p = 0,04) e raça (os caucasianos foram mais prevalentes no grupo mTOR, p = 0,012).Não houve diferença entre os dois grupos na sobrevida do enxerto ou do paciente, mesmo após ajuste para idade, sexo, presença de diabetes mellitus ou risco imunológico. Além disso, no subgrupo de doentes com baixo risco imunológico, o uso de mTOR foi associado a uma tendência para a melhoria da sobrevivência dos enxertos renais, embora não estatisticamente significativa (p = 0,06).Conclusão: Apesar do pior prognóstico conferido pelas principais indicações para a conversão de inibidores de mTOR (neoplasia ou disfunção crônica do enxerto) e da idade avançada, não foi encontrada diferença na sobrevida do enxerto ou do doente entre os dois grupos. Em doentes com baixo risco imunológico, o grupo mTOR mostrou uma tendência para melhor sobrevida do enxerto.

Background: Inhibitors of the mammalian target of rapamycin (mTOR) have demonstrated a similar outcome on allograft loss but its impact on patient survival has only recently been evaluated. In this outcome analysis all renal transplants performed at our unit since 1/1/2006 until 12/31/2011, were evaluated. Allograft failure and mortality were compared between patients who were converted to mTOR and those who remained on a calcineurin inhibitor (CNI). Population and Methods: We have evaluated 425 patients (mean age 46±13 years, 60.7% male, 10.1% diabetics, mean follow-up of 44 months). During this period, 123 patients were converted to mTOR: 8 included in a protocol study, 13 due to malignancy and 102 to evidence of chronic pallograft dysfunction. The remaining patients were maintained on a CNI -based regimen. We compared patient and graft survival by Kaplan-Meier analysis and p < 0.05 was considered significant. Results: During the follow-up time, 10 patients died and 28 lost their graft. Baseline characteristics were similar, except for age(converted patients were older, p = 0.012), gender (higher male percentage in mTOR group, p = 0.04) and race (Caucasians were more prevalent in mTOR arm, p = 0.012). There was no difference between the 2 groups on either graft or patient survival, even after adjustment for age, gender, and presence of diabetes mellitus or immunological risk. Moreover, in the subgroup of patients with low immunological risk, the use of mTOR was associated with a trend towards improved renal allograft survival, although not statistically significant (p = 0.06). Conclusion: Despite worse prognosis conferred by the major indications for conversion to mTOR inhibitors (malignancy or chronic allograft dysfunction) and older age, we found no difference on allograft or patient survival between the 2 groups (mTOR versus CNI -based regimen). In patients with low immunological risk, mTOR group showed a trend towards better allograft survival.

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.

Background. Bortezomib, a 26S proteasome inhibitor, is a novel treatment for refractory acute rejection. The main mechanism proposed for its action is the induction of apoptosis of mature plasma cells leading to an interruption of donor-specific antibody production, but other properties may also be involved. Patients and Methods. Four patients presenting with antibody-mediated rejection were treated with bortezomib as rescue therapy. Renal function, proteinuria and anti-HLA antibodies were monitored for 1-3 years. Results. In three cases, graft function recovery and decreased proteinuria occurred, despite the maintenance of donor-specific antibody levels. However, in one case graft function was lost. Side effects were mostly transient. There were no episodes of opportunistic infection. Conclusion. Bortezomib may be effective in antibodymediated rejection by different mechanisms than simply through reducing donor-specific antibody levels. The timing of its introduction and the length of time that donor-specific antibodies have been present may be determinants of its efficacy

The improvement of combined antiretroviral therapy regimens has made solid organ transplantation a therapeutic option for patients with human immunodeficiency virus (HIV) infection. Generally, HIV-2 infectionpresents a slower clinical progression and immunological degradation than HIV-1. HIV-2 infection treatment can be challenging when a complex immunosuppressive regimen is combined with antiretroviraltherapy. The authors report the first case in Portugal of renal transplantation in an HIV-2 patient. A 54-year-old man from Guinea-Bissau was diagnosed with HIV-2 infection on starting haemodialysis in Portugal in 1998. At diagnosis, HIV infection staging revealed undetectable plasma HIV- 2 RNA and T-cell CD4 counts of 808 cells/μl, with no need for combined antiretroviral therapy during follow-up. The patient underwent renal transplantation from a deceased donor in March 2011. He developed delayed graft function and started therapy with methylprednisolone and thymoglobulin. The patient gradually recovered renal function and was discharged after two weeks with serum creatinine of 2.3 mg/dL. The HIV-2 RNA levels remained undetectable, but T-cell CD4count decreased to less than 200 cells/μl and combined antiretroviral therapy with abacavir, lamivudine and raltegravir was started. Nine months after transplantation, the patient has a serum creatinine of 1.5 mg/dL and a nonreplicating HIV status