ABSTRACT Introduction: Central vein catheterization (CVC) is one of the main risk factors for central vein stenosis (CVS) occurrence in the hemodialysis population. In this work we aimed to evaluate previous central venous manipulation, clinical presentation, and complications in hemodialysis patients with proved CVS. Material and Methods: We retrospectively reviewed all venous angiographies in patients attending our public hospital center for hemodialysis treatment from 2013 to 2018 (n=209). In patients with confirmed CVS (n=29, 14%), we evaluated history of prior CVC and cardiac rhythm devices (CDR), as well as demographics and cardiovascular risk factors. Results: We identified 31 CVS in 29 patients who underwent venous angiography. Most of these patients, 75.9% (n=22), had at least one CVC (ipsilateral or not); at least one previous ipsilateral short-term CVC was found in 34.4% (n=10) of patients and at least one previous ipsilateral long-term CVC was found in 41.4% (n=12) of patients. All patients who had a prior CRD (n=4, 13.8%), had developed an ipsilateral CVS. Conclusion: Prevalence of detected CVS in our population was significant and is likely underestimated. A high percentage of patients with CVS had an history of previous ipsilateral CVC. The number of patients with previous short-term CVC was similar to that of previous long-term CVC, hinting an important role of short-term CVC as a risk factor do CVS.

ABSTRACT Encapsulating peritoneal sclerosis (EPS) is a rare complication of peritoneal dialysis which mortality can reach 50%. The usual treatment involves suspension of the technique, medical treatment, and surgical enterolysis. We report the case of a 36-year-old female who undergone continuous ambulatory peritoneal dialysis without complications for 10 years. She presented at the emergency department with abdominal pain and a diagnosis of peritonitis was assumed. The patient developed a systemic inflammatory response, and her abdominal computer tomography (CT) scan showed multiple parietal calcifications. After multiple broad-spectrum antibiotics, an undetermined febrile syndrome persisted, and parenteral nutrition was started. An EPS diagnosis was established and treatment with tamoxifen was proposed. Exploratory laparoscopy was decided, and the intraoperative findings were consistent with EPS. The patient was submitted to extensive enterolysis. A clinical improvement led to a discharge after 60 days of hospitalization. After more than 30 months with tamoxifen, she remains on hemodialysis and doing well. There are no randomized controlled trials to guide EPS management and the following procedures are more difficult to decide, who makes these reports important to the reflection. We describe a case of successful treatment of EPS, with a very severe presentation. The management with enterolysis and tamoxifen contributed decisively to this outcome.

RESUMO Introdução: Um acesso vascular em bom funcionamento é vital para pacientes em hemodiálise regular. A bandagem do acesso é indicada na síndrome de roubo associada a alto fluxo. Permite a redução do fluxo de acesso enquanto mantém a perfusão distal do membro. No entanto, este procedimento tem algumas limitações, pois pode causar hemorragia, infecção, formação de aneurisma, trombose de acesso em casos de excesso de bandagem (overbanding) ou, de outra forma, redução insuficiente do fluxo vascular. Outras técnicas cirúrgicas para obter o mesmo benefício seriam úteis. Métodos: Foi realizada uma técnica de bandagem modificada sem colocação endovascular do balão de angioplastia, que é uma alternativa viável às outras técnicas. Esta cirurgia foi realizada em pacientes em diálise crônica com síndrome de roubo. Os fluxos de acesso pré e pós-operatório foram medidos e a resolução dos sintomas foi registrada. A taxa de permeabilidade primária foi definida como a sobrevivência do acesso livre de intervenção desde o tempo operatório. Resultados: Verificamos que essa técnica permitiu redução do fluxo de acesso em todos os nossos seis pacientes, com resolução total dos sintomas em todos os pacientes. A taxa de patência primária em 12 meses foi de 100%. Nenhuma complicação maior foi observada durante nosso acompanhamento. Conclusões: Esta técnica permite a correção de fístulas arteriovenosas de alto fluxo de forma eficiente e segura, podendo ser uma alternativa viável a outros procedimentos de bandagem.

ABSTRACT Background: A well-functioning vascular access is vital to patients on regular hemodialysis. Banding the access is indicated in high-flow-associated steal syndrome. It allows for the reduction of access flow while maintaining distal limb perfusion. Nonetheless, this procedure has some limitations as it can cause hemorrhage, infection, aneurysm formation, thrombosis of access in cases of overbanding, or otherwise insufficient reduction of vascular flow. Other surgical techniques to achieve the same benefit would be useful. Methods: We performed a modified banding technique without endovascular placement of the angioplasty balloon, which is a viable alternative to other techniques. This surgery was performed in patients on chronic dialysis with steal syndrome. Pre- and post-operative access flows were measured and resolution of symptoms was recorded. Primary patency rate was defined as the intervention-free access survival from the operative time. Results: We verified that this technique allowed for access flow reduction in all our six patients, with total resolution of symptoms in all patients. Primary patency rate at 12 months was 100%. No major complications were noted during our follow-up. Conclusions: This technique allows for correction of high-flow arteriovenous fistulas in an efficient and safe way, and can be a viable alternative to other banding procedures.

ABSTRACT Hepatitis C virus (HCV) is widely prevalent worldwide, with an estimated 180 million people infected. Its manifestations are not limited to hepatic disease, as it has widely known immunomodulator and oncogenic effects. Most HCV associated autoimmune and lymphoproliferative diseases have been shown to subside after successful antiviral treatment. However, viral eradication doesn't always equal lymphoma cure. In some cases, the oncogenic effect lasts well beyond viral elimination. Although the new direct anti-viral agents (DAA) have proved to be safe and effective in treating HCV (with sustained viral responses of 91-95%), this treatment has inherent toxicities. Further, immunologic manifestations of HCV-associated diseases, when present, may require broad immunosuppression in association with the antiviral treatment. We present a case that illustrates the complexities of treating these viral mediated immunologic and lymphoproliferative diseases

Introduction: The use of iodinated contrast angiography in the diagnostic and therapeutic approach to arteriovenous access (AVA) problems is limited by nephrotoxicity and allergic reactions. The use of alternatives such as CO2 or ultrasound guidance has increased over the last few decades. Purpose: To evaluate the results and complications of the diagnostic and therapeutic procedures of AVA performed at our centre without the use of iodinated contrast. Methods: We evaluated retrospectively all patients submitted to endovascular diagnostic and/or therapeutic procedures using CO2 or ultrasound at our hospital between January 2013 and December 2016. Results: 30 procedures were performed in 22 patients: 15 ultrasound-guided angioplasties and 15 CO2 procedures (14 angioplasties and 1 diagnostic angiography). The mean age of patients was 74±10 years (41--94). Most procedures (90%) were performed on proximal arteriovenous fistulas (AVFs) and 3 were performed on distal AVFs. Iodinated contrast was not used because of its potential nephrotoxicity. Ultrasound-guided angioplasty was performed to treat outflow stenoses in the majority (73%) of the cases. The result was favourable in all procedures. One was complicated by venous rupture. Regarding angioplasties with CO2, outflow stenoses were the most treated (38%). The result was favourable in all procedures. Diagnostic angiography with CO2 was performed in a patient with signs of limb venous hypertension and was inconclusive. There were two complications in CO2 procedures: formation of pseudoaneurysm at the place of insertion of the introducer (n=1) and transient headache and nausea (n=1). Three of the patients who underwent angioplasty with CO2 and one patient who underwent ultrasound-guided procedure were submitted to balloon-assisted maturation. Conclusion: In our experience, the use of alternative methods with no iodinated contrast (CO2/ultrasound) in the evaluation and treatment of vascular access problems in patients with renal dysfunction is effective and safe

Lupus nephritis is a common complication of systemic lupus erythematosus (SLE), usually developing early in the course of the disease. Almost all patients with lupus nephritis present with positive ANA and anti-dsDNA, Hypocomplementaemia and renal manifestations (haematuria, proteinuria and/or renal failure). However, in a small number of patients, the initial presentation is lupus nephritis with absent serology or clinical features of systemic lupus erythematosus

Hepatitis C virus (HCV) infection remains prevalent in chronic kidney disease (CKD) patients. In a posttransplant patient, it can increase the risk for several complications such as transplant glomerulopathy and cryoglobulinaemia. We describe a 69 year-old woman with chronic kidney failure secondary to autosomal dominant polycystic kidney disease (ADPKD) on haemodialysis since January 1989. She had HCV infection (genotype 1b) diagnosed within the dialysis period. Liver biopsy revealed signs of chronic hepatitis. Ten years later, she underwent a deceased donor kidney transplant. She maintained normal kidney allograft function and subnephrotic proteinuria. In July 2015, she was hospitalized with necrotic ulcers in both legs. Laboratory findings revealed type II cryoglobulinaemia and low complement levels. HCV viraemia was high. Cutaneous biopsy showed a leukocytoclastic vasculitis. It was decided to treat cryoglobulinaemia and HCV infection with new direct-acting antivirals agents (DAAs) sofosbuvir/ledipasvir during 12 weeks. Skin ulcers improved and HCV RNA was undetectable after 4 weeks of treatment. Patient showed good tolerance for drug regimen. Proteinuria increased to nephrotic range after DAAs initiation. Donor-specific antibodies class I and II were negative and a kidney allograft biopsy demonstrated features of focal segmental glomerulosclerosis. Exacerbation of proteinuria in our patient could be a possible adverse effect of DAAs therapy, rarely reported in other cases

Introdução: O envelhecimento populacional tem condicionado um aumento progressivo de doentes muito idosos em hemodialise. Estes doentes apresentam multiplas comorbilidades que agravam o prognostico em dialise e que tem impacto na sua qualidade de vida. Material e Métodos: Estudo observacional retrospetivo de doentes integrados em programa regular de hemodialise com idade igual ou superior a 80 anos entre janeiro/2004 e dezembro/2011. As comorbilidades foram estratificadas utilizando o score de Charlson e relacionadas com a mortalidade. Na analise de sobrevida foram utilizadas as curvas de Kaplan-Meier. Resultados: Foram avaliados 59 doentes, 35 do sexo feminino e 24 do sexo masculino, com 84 ± 3 anos. A data de inclusao em programa regular de hemodialise a taxa de filtracao glomerular calculada pela formula MDRD era de 10,8 ± 2,5 ml/minuto. O score inicial de Charlson era de 8 ± 3 e aumentou no final do follow-up para 11,5 2,9; p < 0,01. Um score de Charlson igual ou superior a 8 associou-se a maior numero de dias de internamento (878 vs. 360; p < 0,005) e a uma sobrevida de 56% aos 12 meses e 31% aos 24 meses. A mortalidade ate ao final do follow-up (20,4 15,7 meses) foi de 55,9 %, com uma mortalidade precoce (< 3 meses) de 27,3 %. Este ultimo grupo apresentava um score de Charlson mais elevado no inicio de dialise (13,0 ± 1,7 vs. 6,4 1,2; p < 0,01). Conclusão: Os beneficios da dialise na sobrevida e qualidade de vida dos doentes muito idosos tem sido questionados . Na nossa serie, mais de ¼ dos doentes faleceram nos primeiros 3 meses, correspondendo a scores de comorbilidade mais elevados. Indices de comorbilidade como o de Charlson podem auxiliar na determinacao do prognostico vital a curto prazo, mas a decisao individualizada deve sempre prevalecer.

Introduction: The population ageing has conditioned a progressive increase of very old patients on haemodialysis. These patients present multiple comorbidities that worsen the prognosis in dialysis and have an impact on their quality of life. Material and Methods: A retrospective observational study was performed, analysing all patients over 80 years of age that started regular haemodialysis between January 2004 and December 2011. The comorbidities were stratified using the Charlson score and correlated with mortality. Survival analysis was performed with Kaplan-Meier curves. Results: Fifty-nine patients were included, 35 females and 24 males, with a mean age of 84 �± 3 years. At the start of dialysis, the estimated glomerular filtration rate calculated using the modification of diet in renal disease (MDRD) formula was 10.8 �± 2.5 mL/min /1.73 m2. The initial Charlson score was 8 ± 3 and became higher at the end of follow-up (11.5 �± 2.9; p < 0.01). A Charlson score ≥ 8 was associated with more hospitalization days (878 vs. 360; p < 0.005). The survival rate was 56 % at 12 months and 31% at 24 months. The mortality rate at the end of follow-up (20.4 �± 15.7 months) was 55.9%, with a mortality rate of 27.3% at 3 months. The patients with early death presented a higher Charlson score (13.0 ± 1.7 vs. 6.4 �± 1.2; p < 0.01) at the beginning of dialysis. Conclusion: The benefits of dialysis in survival and quality of life in very elderly patients have been questioned. In our series, more than 1/4 of the patients died in the first 3 months of dialysis, corresponding to higher comorbidity scores. The use of comorbidity scores like the Charlson’s may assist in the assessment of the short-term prognosis, but the individualized decision should prevail in all cases.

Objetivo: Avaliar na década de 90 e 2000 os fatores preditores de rejeição aguda (RA) aos 6 meses pós transplante renal (TR) e o seu efeito na sobrevida censurada do enxerto e do doente. Material e Métodos: Análise retrospetiva dos casos de RA efetuada separadamente em dois períodos: 1990-1999 e 2000-2009. Na avaliação dos fatores de risco para RA foi utilizado um modelo de regressão logística multivariada. Procedemos à construção de curvas comparativas de sobrevivência do enxerto entre paciente com e sem RA pelo método de Kaplan-Meier em cada período. A regressão de Cox multivariada permitiu identificar os preditores de sobrevivência censurada do enxerto e doente, usando como modelo: rejeição aguda, idade (< 40 vs ≥ 40 anos) e sexo do recetor, tempo em HD/DP (< 36 vs. ≥ 36meses), dador vivo vs. cadavérico (apenas na década de 2000), incompatibilidades HLA (0-3 vs. 4-6), PRA (≤ 15 vs. > 15%), número de TR prévios (< 2 vs. ≥ 2), status de hepatite B/C, idade (< 38 vs. ≥ 38 anos) e sexo do dador, episódio de necrose tubular aguda (NTA), uso de ATG na imunossupressão (IS) de indução, uso de MMF ou Tacrolimus (apenas na década de 2000) na IS de indução/manutenção. Resultados: Num total de 1299 transplantes renais, 644 (49.5%) foram realizados na década de 90 e 655 (50.5%) na década de 2000. A RA foi mais frequente na década de 90 (26.2% vs. 11.1%, p < 0.001). Nesta década, os fatores de risco para RA foram o não-uso de ATG (OR 1.88, p = 0.025) e a idade do recetor < 40 anos (OR 2.39, p = 0.001). Na década de 2000, NTA (OR 1.895, p = 0.046) e PRA > 15% (OR 3.519, p = 0.001) foram os fatores de risco identificados. A sobrevivência censurada do enxerto aos 5 anos foi inferior nos casos de RA na década de 90 (81% vs. 94%, p < 0.001) e 2000 (81% vs. 91%, log rank p = 0.004). Na análise de regressão Cox, os preditores de menor sobrevivência do enxerto na década de 90 foram a RA (HR 2,436, p < 0.001), idade do recetor < 40 anos (HR 1.984, p = 0.002) e idade do dador ≥ 38 anos (HR 1.961, p = 0.002). Na década de 2000 foram identificadas a NTA (HR 3.247, p < 0.001) e idade de dador ≥ 38 anos (HR 2.32, p = 0.017). Não encontramos diferenças na sobrevida do doente aos 5 anos em ambos períodos. Apenas o status de Hepatite B/C (HR 1.714, p = 0.023) foi preditor independente de morte do doente na década de 90, enquanto que na década de 2000, os preditores significativos foram TR prévio (HR 2,718, p = 0.049) e RA (HR 2,619, p = 0.023). Conclusão: A partir de 2000, a RA aos 6 meses deixou de ser um preditor independente de sobrevivência do enxerto. Inversamente, passou a ter um efeito negativo independente na sobrevivência do doente. Os avanços na IS permitiu o TR em recetores cada vez mais sensibilizados, com melhoria na sobrevida do enxerto nestes casos mas com possível efeito desfavorável na sobrevida do doente.

Objective: To determine risk factors for acute rejection in the first 6 months post- transplant and their effect on death-censored graft and patient survival in the 990-1999 and 2000-2009 periods. Patients and Methods: Retrospective analysis of acute rejection episodes was performed separately in two periods: 1990-1999 and 2000-2009. Multivariate logistic regression analysis was performed in order to identify risk factors for acute rejection. Death-censored graft and patient survival comparison between patients with or without acute rejection occurrence was performed by Kaplan-Meier analysis. Multivariate Cox regression analysis identified independent predictors for death-censored graft and patient survival, assuming the following model: acute rejection, patient’s age (< 40 vs. ≥ 40 years) and gender, time on haemodialysis / peritoneal dialysis (< 36 vs. ≥ 36 months), live vs. deceased donor (only after the year 2000), HLA mismatches (0-3 vs. 4-6), PRA (≤ 15 vs. > 15%), number of previous kidney transplants (< 2 vs. ≥ 2), status of hepatitis B/C, donor´s age (< 38 vs. ≥ 38 years) and gender, delayed graft function (DGF), ATG use in induction immunosuppression (IS), MMF or Tacrolimus use in induction / maintenance IS (after 2000). Results: A total of 1299 kidney transplants were analyzed. Acute rejection was more frequently diagnosed in the 1990s (26.2% vs. 11.1%, p < 0.001). Over this period, ATG non-use (OR 1.88, p = 0.025) and patients’ age < 40 years (OR 2.39, p = 0.001) were risk factors for AR while, after 2000, DGF (OR 1.895, p = 0.046) and PRA > 15% (OR 3.519, p = 0.001) were identified. Five years death-censored graft survival was lower in AR cases in the 1990s (81% vs. 94%, p < 0.001) and after 2000 (81% vs. 91%, log rank p = 0.004). Independent predictors for worse death-censored graft survival in 1990-1999 patients were AR (HR 2,436, p < 0.001), patient´s age < 40 years (HR 1.984, p = 0.002) and donor´s age ≥ 38 years (HR 1.961, p = 0.002), while after 2000, DGF (HR 3.247, p < 0.001) and donor´s age ≥ 38 years (HR 2.32, p = 0.017) were identified. No difference was found at five-year patient survival in both groups. Only hepatitis B/C (HR 1.714, p = 0.023) was identified as an independent predictor for patient death in the 1990-1999 period, while after 2000, retransplantation (HR 2,718, p = 0.049) and AR (HR 2,619, p = 0.023) were determinant. Conclusion: After the year 2000, AR was no longer an independent predictor for poor graft survival. Inversely, AR began to play a deleterious effect on patient survival. Advances on immunosuppressive drugs allowed the increase of kidney transplant on hypersensitized patients, with improvement of graft survival in those patients but also with a possible deleterious effect on patient survival.

Objectivo: Determinar a incidência, etiologia, preditores e prognóstico dos casos de peritonite nos nossos doentes em Diálise Peritoneal (DP). Doentes e métodos: Um estudo observacional retrospectivo foi realizado em 59 doentes durante um período de 10 anos e englobou a epidemiologia, apresentação clínica, perfil microbiológico, tratamento e prognóstico dos nossos casos de peritonite. Resultados: Foram contabilizadas 88 peritonites em 31 doentes (idade média 43 ±15 anos), com ocorrência predominante no sexo masculino (68,0% vs. 39.0%, p < 0,01) e incidência calculada de 0,57 peritonites.doente.ano. O agente mais frequentemente identificado foi o Staphylococcus coagulase-negativo (25,9%). Encontrámos associação entre as peritonites por Staphylococcus aureus (17,0%) e a ocorrência de peritonites de repetição (44,4% vs. 14,3%, p = 0,02). Nestes casos, metade dos doentes eram portadores nasais e cinco casos (33%) foram precedidos de infecção do orifício de saída do cateter por este agente. As peritonites estéreis (15,9%) apresentaram contagem leucocitária peritoneal inicial inferior (< 1500 cell/mm3: 64,3% vs. 32,4%, p = 0,02) e as onze peritonites refractárias contabilizadas associaram -se a maior duração da antibioterapia (34 vs. 20 dias, p < 0,01), de internamento (16 vs. 5 dias, p < 0,01) e a remoção do cateter de DP foi necessária em oito casos. A cura foi atingida na maioria dos casos (n = 80, 90, 9%) mas sete doentes foram transferidos para hemodiálise e ocorreu uma morte por peritonite. A sobrevida da técnica aos 36 meses dos doentes com peritonite foi de 80%. A transferência da hemodiálise (OR 5,9; CI 95%: 1,2 -29,3) e o sexo masculino (OR 5,1; CI 95%: 1,02 - 25,1) foram os fatores de risco apurados para ocorrência de peritonite no primeiro ano da técnica. Considerando todos os doentes, o risco de peritonites cumulativas ( ≥ 3 episódios) foi superior nos doentes com episódio de peritonite no primeiro ano da técnica (OR 10,28; CI 95%: 1,27 -83,32). A idade e diabetes mellitus não conferiram maior risco para estes eventos. Conclusão: Os resultados obtidos foram globalmente satisfatórios. A transferência da hemodiálise e o sexo masculino foram identificados como fatores de risco para peritonite no primeiro ano da técnica. Este evento precoce está associado a maior risco para a ocorrência de três ou mais peritonites nestes doentes durante o tempo em DP.

Aims: Evaluate the incidence, aetiology, predictors and outcomes of peritonitis in our chronic peritoneal dialysis (PD) patients. Patients and methods: A retrospective observational study was carried out in 59 patients during a ten-year period, which included the epidemiology, clinical presentation, microbiology profile, treatment and outcomes of all peritonitis episodes. Results: A total of 88 peritonitis occurred in 31 patients (mean age 43 ±15 years), with a peritonitis rate of 0.57 episodes.patient.year. Male gender (68.0% vs. 39.0%, p < 0.01) was associated with events. Coagulase-negative Staphylococcus was the most frequent agent (25.9%). Staphylococcus aureus peritonitis (17.0%) was associated with repeat peritonitis (44.4% vs. 14.3%, p = 0.02). Nasal carriage of this agent was found in half the patients and five (33.3%) episodes were preceded by exit-site infection. Culture negative peritonitis (15.9%) had lower initial peritoneal leukocyte count (< 1500 cell/mm3: 64.3% vs. 32.4%, p = 0.02). Eleven refractory peritonitis were reported and associated with longer time of treatment (34 vs. 20 days, p < 0.01) and hospital stay (16 vs. 5 days, p < 0.01). The peritoneal catheter was removed in eight cases. Cure was achieved in the majority of cases (n = 80; 90.9%), seven patients were transferred to haemodialysis, and one died. The technique survival rate at 36 months was 80%. Greater risk of peritonitis in the first year was identified in patients transferred from haemodialysis (OR 5.9; CI 95%: 1.2 -29.3) and male gender (OR 5.1; CI 95%: 1.02 - 25.1). Considering all PD patients, first year peritoneal dialysis episode was associated with higher risk for cumulative peritonitis (≥ 3) (OR 10.28; CI 95%: 1.27 -83.32). Diabetes and older age were not associated to higher risk of these events. Conclusion: The overall results of peritonitis episodes were satisfactory. Transfer from haemodialysis and male gender were associated with higher risk for first -year peritonitis. This early event was associated with a greater risk of occurrence of three or more peritonitis in those patients.