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.

ABSTRACT Peritonitis is one of the main complications of peritoneal dialysis and accounts for considerable mortality and hospitalization. It is usually treated with intraperitoneal antibiotherapy, as it is the best way to achieve high concentrations at the site of infection. We report a case of an 86-year-old female patient with end-stage renal disease under continuous ambulatory peritoneal dialysis, who was admitted to our hospital with complaints of intense diffused abdominal pain. The effluent culture yielded Staphylococcus hominis only sensible to vancomycin and linezolid. She was diagnosed with peritonitis secondary to Staphylococcus hominis infection and treated with oral linezolid without cateter removal. Adequate linezolid peritoneal fluid concentration (between 3 and 20 μg/mL) was achieved and the antibiotic therapy was maintained for 21 days with clinical and analytical improvement. According to our knowledge, this was the first Staphylococcus peritonitis in a peritoneal dialysis patient, successfully treated with oral linezolid and has had linezolid levels monitored in the peritoneal dialysis effluent.

Background: Anemia is a common complication of Chronic Kidney Disease (CKD), in which iron deficiency's (ID) role is frequently underrated. In CKD, anemia has been associated with higher morbidity and lower quality of life. Nonetheless, reported treatment rates of anemia in CKD are low and guidelines' variability and/or absence for its management and treatment may be preventing patients from receiving optimal treatment. Within this context, we aimed to assess the agreement level on anemia and iron deficiency diagnosis, management, and treatment in CKD patients, by Portuguese physicians in Nephrology, through a Delphi Panel. Methods: A group of seven medical experts in Nephrology and Transfusion Medicine was assembled, and a focus group was conducted, in which 28 statements were agreed upon. Then, a two-round Delphi Panel using a Likert scale was conducted online, inviting Portuguese Society of Nephrology associates to participate. Results: Answers were collected from 76 participants in Round 1 and consensus level was obtained for 1 statement, 57 (75%) respondents fully disagreeing on transfusing all patients with hemoglobin below 9 g/dl, regardless of the clinical situation. The remaining 27 statements were used in Round 2, none obtaining consensus level and 14 statements being categorized as qualified majority: 4 on diagnosis, 3 on disease management, and 7 on treatment. Discussion: Our study showed a lack of consensus on diagnosis, management, and treatment of anemia in CKD patients among the nephrology community in Portugal. Overall, our results illustrated the heterogeneity of national clinical practices in: laboratory parameters' choice; cutoff values defining anemia and/or ID; parameter-based therapeutic decisions. Nonetheless, it was shown clear that patient's individual characteristics, clinical settings, and the physician's "clinical sense" seem to be considered to a further extent than the available guidelines. Future studies should be considered to develop recommendations that can be widely accepted.

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.

É cada vez mais frequente o esforço desenvolvido por investigadores e estudiosos no sentido de situar o direito nos respetivos contextos social, político, histórico e cultural. Verifica-se, simultaneamente, a necessidade de conferir ao direito e às ciências sociais novos papéis e recursos. Assim, propomos-nos ir em busca das muitas interseções entre o direito, a cultura e as humanidades, apresentando para tanto quatro grandes linhas de indagação: (1) a interlegalidade no quotidiano; (2) a sinestesia do direito; (3) os estudos sociojurídicos de natureza material; e (4) as ecologias interativas de saberes e metodologias. É essa a primeira parte do artigo. A segunda e a terceira partes debruçam-se sobre duas relações interdisciplinares concretas e bastante recentes: entre direito e música, e entre direito e comida. Nessa conformidade, avançamos a ideia de que será oportuno expor os alunos, formandos e os profissionais da área em geral à vantagem decorrente de uma compreensão das ligações existentes entre o direito, a cultura e as humanidades.

L'effort fourni par les chercheurs et les érudits dans le but de situer le droit dans leurs respectifs contextes social, politique, historique et culturel est de plus en plus notoire. Simultanément, il est donné de constater un besoin de conférer au droit et aux sciences sociales de nouveaux rôles et ressources. Dès lors, nous nous proposons de partir en quête des nombreuses intersections existant entre le droit, la culture et les sciences humaines, en présentant, pour ce faire, quatre grandes lignes de recherche: (1) l'interlégalité au quotidien; (2) la synesthésie du droit; (3) les études sociojuridiques de nature matérielle et (4) les écologies interactives de savoirs et de méthodologies. Il s'agit là de la première partie de l'article. La seconde et la troisième se penchent sur deux relations interdisciplinaires concrètes et assez récentes: entre droit et musique et entre droit et alimentation. C'est en vertu de ce qui précède que nous avançons l'idée qu'il serait opportun d'exposer les étudiants, les apprenants et les professionnels de ce domaine en général à l'avantage qui découle d'une bonne compréhension des liens existant entre le droit, la culture et les sciences humaines.

Ever more often, researchers and scholars endeavor to situate law in its social, political, historical and cultural contexts. At the same time, there is a need to invest law and the social sciences with new roles and resources. We thus propose to look for the many intersections of law, culture and the humanities by presenting four topical preoccupations: (1) interlegality in everyday life; (2) the synesthesia of law; (3) material socio-legal studies; and (4) interactive ecologies of knowledges and methodologies. This will constitute part one of the paper. Parts two and three will look at two particular and very recent interdisciplinary relationships: those between law and music and between law and food. We thus propose it would be appropriate to expose students, learners and practitioners of all kinds to the difference that an understanding of the links between law, culture and the humanities makes.

Resumo Introdução: O hiperparatiroidismo secundário é alvo de várias estratégias terapêuticas, incluindo a utilização de cinacalcet, sendo escassos os resultados referentes aos doentes em diálise peritoneal. Objetivo: Propusemo-nos a avaliar a eficácia da terapêutica com cinacalcet no tratamento dos doentes com hiperparatiroidismo secundário numa unidade portuguesa de diálise peritoneal. Métodos: Estudo retrospectivo que incluiu 27 doentes em diálise peritoneal com hiperparatiroidismo secundário moderado a grave (PTHi > 500 pg/mL) tratados com cinacalcet. Foram analisados os dados demográficos, clínicos e laboratoriais à data de início da terapêutica, ao segundo, quarto e sexto mês e à data do fim do estudo ou da suspensão do mesmo. Resultados: Os doentes estavam em diálise peritoneal há 30,99 ± 16,58 meses e foram tratados com cinacalcet durante 15,6 ± 13,4 meses; 21 (77,8%) doentes apresentaram efeitos adversos gastrointestinais. Os valores de PTHi no início da terapêutica com cinacalcet eram 1145 ± 449 pg/mL. Os últimos valores de PTHi foram 1,131 ± 642 pg/mL. A redução da PTHi foi estatisticamente significativa aos 2 meses após o início do cinacalcet (p = 0,007), mas não nas avaliações subsequentes. Conclusão: Torna-se necessário o desenvolvimento de novas formas de apresentação do cinacalcet, de modo a evitar os efeitos adversos gastrointestinais e melhorar a adesão terapêutica.

Abstract Introduction: Secondary hyperparathyroidism is the target of several therapeutic strategies, including the use of cinacalcet. Most studies were done only in hemodialysis patients, with few data from peritoneal dialysis patients. Objective: The aim of our work was to evaluate the effectiveness of cinacalcet in secondary hyperparathyroidism in a one-center peritoneal dialysis patients. Methods: A retrospective study was performed in 27 peritoneal dialysis patients with moderate to severe secondary hyperparathyroidism (PTHi > 500 pg/mL with normal or elevated serum calcium levels) treated with cinacalcet. Demographic, clinical and laboratory parameters at the beginning of cinacalcet therapy, second, fourth, sixth months after and at the time it was finished were analyzed. Results: Patients were under peritoneal dialysis at 30.99 ± 16.58 months and were treated with cinacalcet for 15.6 ± 13.4 months; 21 (77.8%) patients showed adverse gastrointestinal effects; PTHi levels at the beginning of cinacalcet therapy were 1145 ± 449 pg/mL. The last PTHi levels under cinacalcet therapy was 1131 ± 642 pg/mL. PTHi reduction was statistically significant at 2 months after the beginning of cinacalcet (p = 0.007) but not in the following evaluations. Conclusion: It is necessary the development of new forms of cinacalcet presentation, in order to avoid gastrointestinal effects adverse factors and to improve therapeutic adherence.

A cardiomiopatia takotsubo (CT) e uma entidade que mimetiza clinicamente a sindroma coronaria aguda (SCA) e que poderá ser subdiagnosticada na população hemodialisada. Este tema e revisto com base no caso de uma doente de 68 anos. Habitualmente a CT apresenta -se como um enfarte agudo do miocardio. No entanto, ao contrario da SCA, nao sao detectadas lesões coronárias obstrutivas nem existe uma correlação entre os defeitos de motilidade cardíaca (disfunção cinética apical e hipermotilidade basal) e a ligeira elevação dos marcadores de necrose miocardica. Na ventriculografia este defeito apresenta-se como uma imagem de jarro, dai o nome Takotsubo (armadilha de polvos, da tradução do japonês em que “tako” significa polvo e “tsubo” jarro). Ate a data, com base nos dados provenientes de modelos animais e a semelhança da lesao cardiaca induzida pelo feocromocitoma, parece que o mecanismo fisiopatologico e decorrente de uma descarga adrenergica aguda. Trata -se de uma entidade difícil de diagnosticar no doente renal crónico, dificuldade que advém da semelhança clinica entre a CT e a SCA, elevada prevalência de factores de risco cardiovascular e pesada morbilidade cardiovascular nesta população

Takotsubo cardiomyopathy is an uncommon clinical entity that mimics acute coronary syndrome (ACS) and may be underdiagnosed among haemodialysis (HD) patients. This topic is, therefore, reviewed based on a clinical case of a 68-year-old woman undergoing haemodialysis. Usually, Takotsubo cardiomyopathy presents itself as an acute myocardial infarction. However unlike ACS, neither a coronary obstructive disease is found nor do cardiac biomarkers correlate with the extensive wall motions defects (apical and midventricular kinesis dysfunction along with basal hypermotility). This defect translates into a jarshaped appearance in ventriculography, and therefore its Takotsubo name (octopus trap, in Japanese “tako” means octopus and “tsubo” means jar). So far, data available from animal models and its resemblance with pheochromocytoma-induced cardiomyopathy suggests that an adrenergic surge might be an underlying mechanism. The overlapping clinical features of takotsubo cardiomyopathy and ACS, the high prevalence of cardiovascular risk factors and the already superimposed cardiovascular disease in chronic kidney disease make it difficult to diagnose among these patients

A diálise peritoneal é uma opção válida para o tratamento da doença renal crónica estádio 5. Como este procedimento provoca um aumento da pressão intra-abdominal, pode causar uma “fuga” pleuroperitoneal (hidrotórax). Esta complicação não infecciosa, sendo rara, pode ser fatal para doentes em diálise peritoneal; provavelmente secundária à passagem trans-diafragmática de líquido através de uma comunicação pleuroperitoneal. A sua etiologia não está ainda definida, foram propostas diversas causas: defeitos congénitos do diafragma; gradiente de pressão pleuroperitoneal; distúrbios da drenagem linfática; defeitos adquiridos do diafragma, como o aparecimento de fenestrações ou a escassez de fibras musculares diafragmáticas, situações agravadas pela pressão intra-abdominal durante a permanência de dialisante na diálise peritoneal. A cintigrafia peritoneal (peritoneocintigrafia 99mTc-MAA) é uma ferramenta útil no diagnóstico de comunicação pleuroperitoneal. Apresentamos quatro casos de hidrotórax associados a comunicação pleuroperitoneal num total de 290 doentes tratados com diálise peritoneal entre 1999 e 2014, na nossa Unidade. Analisamos a incidência, estratégia diagnóstica e terapêutica desta complicação.

Peritoneal dialysis is an established treatment option for patients with end-stage renal disease. As this procedure causes high pressure in the abdomen, it might lead to peritoneopleural leakage (hydrothorax). The latter is an uncommon non-infectious complication of peritoneal dialysis patients, possibly secondary to trans-diaphragmatic fluid leakage through a pleuroperitoneal communication. The aetiology of this condition is still unclear. A variety of mechanisms have been proposed: congenital diaphragmatic defects; pleuroperitoneal pressure gradient; lymph drainage disorder; acquired diaphragmatic defects that are a consequence of increased intra-abdominal pressure during the dwell period of peritoneal dialysis, such as fenestrations or acquired scarcity of muscle fibres in the tendinous part of the diaphragm. Peritoneal scintigraphy (99mTc-MAA peritoneoscintigraphy) is a useful diagnostic tool in the management of suspected pleuroperitoneal communication. We report four cases of hydrothorax related to pleuroperitoneal communication in 290 patients treated with chronic peritoneal dialysis, between 1999 and 2014, at our PD Unit. Here we analyse our department’s incidence of this complication and also present own experience in diagnosing and treating it.

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.

Com o objetivo de avaliar a influência de níveis crescentes de inclusão do farelo de girassol (FG) em rações (MS: 92,71%; PB: 27,50%; FDN: 43,57%; FDA: 32,96%; FB: 25,91%) e a atuação deste no desempenho e características de carcaça para suínos em terminação, conduziu-se uma pesquisa no Departamento de Zootecnia da Universidade Federal de Lavras-MG. Foram utilizados 80 suínos mestiços (LD x LW) com peso inicial de 62,20 ± 4,21 kg, sendo 1 macho e 1 fêmea por baia, distribuídos em um delineamento em blocos ao acaso. As rações apresentaram níveis crescentes de inclusão (0, 4, 8, 12 e 16%) de FG. Ao final do ensaio de desempenho os 80 suínos foram abatidos (99,80 ± 6,91kg) e submetidos à avaliação de carcaça (ABCS, 1973). Os níveis crescentes de FG proporcionaram redução linear (P< 0,05) no CRMD; para as demais variáveis não se observou efeito significativo. Na avaliação de carcaça, os níveis crescentes de inclusão de FG não proporcionaram efeito significativo (P>0,05) para as variáveis avaliadas, sendo, entretanto, constatado efeito de sexo, pois os machos apresentaram maiores valores de ETM, P2, AG e RCG e as fêmeas melhor AOL e RPER. Conclui-se que é viável tecnicamente a inclusão de até 16% de farelo de girassol em rações para suínos na fase de terminação.

With the objective to evaluate the influence of increasing levels of inclusion of sunflower meal (SFM) solvent extraction (DM: 92.71%, CP: 27.50%, NDF: 43.57%, ADF: 32.96%, CF: 25.91%, EE: 3,08% and GE: 4390 kcal) on the performance and carcass characteristics of finishing swine, a performance trial was conducted in the Department of Animal Science of the Federal University of Lavras - MG. A total of 80 crossbred pigs (LD x LW) with initial weight of 62.20 ± 4.21 kg were utilized, one barrow and one gilt per experimental unit, allocated in a randomized block design. The treatments were represented by five diets with increasing levels of inclusion (0, 4, 8, 12 and 16%) of SFM. At the end of the experimental period, all pigs were slaughtered (99.80 ± 6.91kg) and submitted to the carcass evaluation by the Brazilian Method of Carcass Evaluation (ABCS, 1973). The increasing levels of SFM shown a linear reduction (P<0.05) in the feed intake, therefore all other variables, shown any significant effect. The carcass data evaluation also shown any significant effect (P>0.05) for any increasing levels of SFM in the diets, however, sex effect was found, in the barrows, which shown higher ETM, P2, AG and RCG and lower AOL in relation to the females In conclusion Sunflower meal should be included up to 16% in pig diet (isocaloric and isolysinic, basis ) with no major effects on growth performance or carcass traits of finishing pigs.