Abstract Introduction: Kidney transplant (KT) recipients have a high risk for adverse outcomes from infections, such as COVID-19. Methods: We have retrospectively reviewed all KT recipients with documented COVID-19 between March 1, 2020, and March 15, 2021, and analyzed patients’ characteristics, clinical course, treatment, and outcomes. Results: We identified 123 patients, 72% were male, with a mean age of 54.5±13.0 years. Twenty percent were asymptomatic, 7% had a nosocomial transmission, and 36% of the remainder required hospitalization. Almost all admitted patients received oxygen, 30% required invasive mechanical ventilation (IMV), more than a half had acute kidney injury, with 10% requiring dialysis, and 20% died. Incidence was comparable to that of the Portuguese population, but the mortality rate was almost four times higher (SMR of 3.768 (95% CI:1.723-7.154). Higher body mass index (OR 1.275, P=0.001), lower baseline graft function (OR 0.968, P=0.015), and nosocomial transmission (OR 13.836, P=0.019) were associated with oxygen demand, whereas female gender (OR 3.801, P=0.031) and lower baseline kidney graft function (OR 0.955, P=0.005), but not body mass index, were associated with IMV and/or death. Conclusion: Mortality rate in KT patients was higher than in the general population and lower baseline kidney function was the most consistent marker for adverse outcomes.

Resumo Introdução: Os receptores de transplante renal (TR) apresentam um alto risco para desfechos adversos de infecções, tais como a COVID-19. Métodos: Revisamos retrospectivamente todos os receptores de TR com COVID-19 documentada entre 1º de Março de 2020 e 15 de Março de 2021, e analisamos as características, curso clínico, tratamento e desfechos dos pacientes. Resultados: Identificamos 123 pacientes, 72% do sexo masculino, com uma média de idade de 54,5±13,0 anos. Vinte por cento eram assintomáticos, 7% apresentaram transmissão nosocomial, e 36% do restante necessitaram de internação. Quase todos os pacientes internados receberam oxigênio, 30% necessitaram de ventilação mecânica invasiva (VMI), mais da metade apresentou lesão renal aguda, com 10% necessitando de diálise, e 20% foram a óbito. A incidência foi comparável à da população portuguesa, mas a taxa de mortalidade foi quase quatro vezes superior (TMP de 3,768 (IC 95%: 1,723-7,154). Maior índice de massa corporal (OR 1,275; P=0,001), menor função do enxerto basal (OR 0,968; P=0,015), e transmissão nosocomial (OR 13,836; P=0,019) foram associados à demanda de oxigênio, enquanto sexo feminino (OR 3,801; P=0,031) e menor função do enxerto renal basal (OR 0,955; P=0,005), mas não índice de massa corporal, foram associados à VMI e/ou óbito. Conclusão: A taxa de mortalidade em pacientes com TR foi mais elevada do que na população em geral e a função renal basal mais baixa foi o marcador mais consistente para desfechos adversos.

ABSTRACT Antineutrophil cytoplasmic antibodies (ANCA) are useful as markers for systemic vasculitis. PR3-ANCA antibodies have been also identified in association with chronic inflammatory and infectious conditions, other autoimmune diseases, malignancy, and certain drugs. The association of PR3 and minimal change disease (MCD) without vasculitis is not an expected finding. We report a case of MCD with PR3-ANCA positive title and no histopathological findings of vasculitis. This reports to an 86-year-old Caucasian woman without relevant past medical history and a normal renal function one month before presentation with sudden-onset nephrotic syndrome and rapidly progressive renal failure. Renal ultrasound was normal. Autoimmune screening using enzyme-linked immunosorbent assay (ELISA) revealed PR3-ANCA high titers (238.7UQ). Renal biopsy did not show vasculitis or crescentic glomerulonephritis. The glomeruli were normal. Autoimmune, inflammatory, infectious and malignant diseases were excluded. MCD was assumed and she started prednisolone with clinical and analytical improvement. ANCA-associated glomerular disease can coexist with a variety of other glomerular diseases including membranous nephropathy, lupus nephritis, IgA nephropathy, and bacterial infection-related glomerulonephritis. This association could be an incidental finding, but there may be an association with MCD not previously reported. Our case emphasizes the importance of performing renal biopsies before embarking on a full-scale immunosuppression therapy based on ANCA title alone.

ABSTRACT In Portugal, as well as in Europe, peritoneal dialysis (PD) use remains low. Reorganization of PD units including a well‑structured peritoneal access management protocol are fundamental to improve the take‑up of this therapy. We analyzed the procedure and outcomes in a PD unit, addressing two key quality questions: at which level of estimated glomerular filtration rate (eGFR) were patients referred to peritoneal cateter placement and whether if it was timely placed. We retrospectively evaluated all patients submitted to catheter placement between 2017 and June 2020. We analyzed the patient journey from Kidney Replacement Therapies (KRT) Option Appointment, until PD start, as well as demographic and clinical variables, including eGFR at four time points (KRT Options Appointment, PD unit evaluation, catheter placement, and PD start). To explore the adequacy of cateter placement schedule, we compared the characteristics of the patients who started PD within 90 days of catheter placement (Early group), and of those who started after the first 90 days (Late group). We analyzed 48 patients in the Early and 27 in the Late group. The Early group presented a lower eGFR on KRT Options Appointment, with timely intervention: eGFR at catheter placement averaged 8.0 ± 2.1 mL/min/1,72m2. PD start occurred at 7.0 ± 1.9 and 8.0 ± 2.4 mL/min/1.72m2, in the Early and Late group, respectively. None of the patients suffered an urgent transition to HD by CVC. Four patients started PD less than 15 days after catheter placement, all of them without complications. PD patients’ admission involves specific tasks. Administrative tools or indicators to evaluate those processes are lacking. A peritoneal access clinic would allow the formalization of this circuit, allowing a quality and equitable approach to dialysis access. We suggest a structured pathway for peritoneal access management.

RESUMO Introdução: A taxa estimada de filtração glomerular (TFGe) com base na cistatina-C sérica (Cis-C) parece ser tão precisa quanto aquela baseada na creatinina sérica (Cr), mas cis-C parece ser um melhor preditor de resultados adversos. Nosso objetivo foi avaliar se a cis-C poderia ser uma ferramenta confiável para a previsão de desfechos adversos em pacientes idosos com doença renal crônica grave (DRC). Métodos: Um grupo de 348 pacientes idosos com DRC em estágio não terminal (estágios 1-4, de acordo com TFGe-EPI Cr e/ou Cis-C), encaminhados para nossa unidade de consulta durante 2016, foi estudado retrospectivamente e dividido em quatro categorias exclusivas: DRC_estágio 4 nenhum (TFGe-Cr≥30mL/min; TFGe -Cis-C≥30mL/min), DRC_estágio 4_Cr apenas (TFGe-Cr <30mL/min), DRC_estágio 4 _Cis-C_apenas (TFGe-Cis-C <30 mL/min), DRC_estágio4_combinado (TFGe-Cis-C <30mL/min. TFGe-Cr <30mL/min). Características basais, preditores de óbito e eventos clínicos (eventos cardiovasculares e internações por doenças cardiovasculares, lesão renal aguda ou eventos infecciosos) foram explorados até dezembro de 2018. Resultados: Uma coorte de 77 ± 7,4 anos, com índice de comorbidade de Charlson modificado (mCCI) de 3 (IQR: 1-4), foi acompanhada durante 29 (IQR: 26-33) meses. Não houve diferenças significativas entre as características dos grupos no estágio 4. A análise de sobrevida foi estratificada pelo acompanhamento aos 12 meses, sendo que no primeiro ano, as curvas de sobrevida dos grupos DRC_estágio4_Cis-C_apenas e DRC_estágio4_ combinado foram significativamente inferiores quando comparadas com os restantes grupos (p = 0,028). Ajustando para idade, sexo e mCCI, DRC_estágio4_Cis-C_apenas, ao contrário do grupo DRC_estágio4_Cr_apenas, teve maiores taxas de eventos clínicos (p <0,05) do que o grupo DRC_estágio4_nenhum. Conclusão: Em pacientes idosos com estadiamento discordante da DRC, a TFGe baseada na Cis-C parece ser um melhor preditor de resultados adversos do que a TFGe baseada na Cr. Pacientes com DRC em estágio 4, definida apenas por Cr, parecem se comportar de forma semelhante àqueles com DRC menos grave.

ABSTRACT Introduction: Estimated glomerular filtration rate (eGFR) based on serum cystatin-C (sCys) seems as accurate as when based on serum creatinine (sCr), but sCys seems a better predictor of adverse outcomes. We aimed to study whether sCys could be a reliable tool for the prediction of adverse outcomes in elderly patients with severe chronic kidney disease (CKD). Methods: A group of 348 elderly patients with non-end-stage CKD (stages 1-4, according to eGFR-EPI sCr and/or sCys), referred to our consultation unit during 2016, was retrospectively studied and divided into four exclusive categories: CKD_stage4_neither (eGFR-sCr≥30mL/min; eGFR-sCys≥30mL/min), CKD_stage4_sCr_only (eGFR-sCr<30mL/min), CKD_stage4_sCys_only (eGFR-sCys<30mL/min) and CKD_stage4_combined (eGFRsCr<30mL/min; eGFR-sCys<30mL/min). Baseline characteristics, predictors of death, and clinical events (cardiovascular events and admissions for cardiovascular, acute kidney injury or infectious events) were explored until December 2018. Results: A 77±7.4 year-old cohort, with a modified Charlson Comorbidty Index (mCCI) of 3 (IQR:1-4), was followed-up during 29 (IQR: 26-33) months. There were no significant differences between the characteristics of the stage 4 groups. Survival analysis was stratified by follow-up at 12 months, and in the first year, survival curves of CKD_stage4_sCys_only and CKD_stage4_combined groups were significantly lower than the other groups (p=0.028). Adjusting for age, sex, and mCCI, CKD_stage4_sCys_only, conversely to CKD_stage4_sCr_only, had higher rates of clinical events (p<0.05) than CKD_stage4_neither group. Conclusion: In elderly patients with discordant CKD staging, sCys-based eGFR seems to be a better predictor of adverse outcomes than sCr-based eGFR. Patients with stage 4 CKD defined by sCr alone seem to behave similar to those with less severe CKD.

ABSTRACT Introduction: Ammonia is a resultant molecule from the protein metabolism that can be neurotoxic when present in high concentrations, causing brain edema and encephalopathy. Extracorporeal blood purification technique (EBPT) can play a role in reducing both ammonia and urea blood levels. However, there are no specific guidelines for its use in hyperammonemia, due to its low incidence and scarce literature on this subject, particularly in adults. Case report: The authors describe a case of a 22‑year‑old previously healthy woman. She presented with polyuria, polydipsia, anorexia, vomiting and significant (>10%) weight loss over a month. Laboratory data revealed hypoglycemia and a high anion gap metabolic acidosis with severe acidemia with normal lactate, serum creatinine of 1.12 mg/dl and 260 (reference value 26‑74)umol/l of ammonia. Urine analysis showed ketone bodies. She evolved with progressive encephalopathy and neurological deterioration. The hypothesis of hyperammonemic encephalopathy secondary to a hereditary metabolic disease was suspected. Medical supportive therapy was initiated. An EBPT for ammonia removal and acid‑base correction was initiated using continuous venovenous hemodiafiltration (CVVHDF) with a drastic neurologic improvement. A fatty acid beta‑oxidation deficit was discovered. The patient was discharged with no neurological changes, with a strict diet free of fat, animal protein and high‑protein vegetables, plus supplementation with benzoate, carnitine, riboflavin, maltodextrine and essential amino acids. Discussion and conclusion: In adults, hyperammonemia related to metabolic disorders is rare, and in the presence of encephalopathy, ECDT should be considered. Ammonia is easily dialysable either by intermittent or continuous techniques. CVVHDF provides a continuous clearance with less rebound effect.

Incremental dialysis is increasingly recognized as a safe and beneficial method of initiating dialysis. Different centers use distinct prescription methods. We discuss the advantages of incremental hemodialysis and the potential benefit of preserving residual renal function as we present our experience. We reviewed the data from 20 incident patients, with a mean follow-up of 9.5 months, who started dialysis with our prescription method, using hemofiltration as the preferred depurative technique. All patients tolerated treatment well; no major complications were reported. Dialysis adequacy targets were achieved. While data are clearly limited, we raise the hypothesis that convective techniques could bring additional benefit in preserving residual renal function in incident patients, and that this strategy should be studied and compared with others.

Background and objectives: To evaluate RRT benefits and risks and to inform patients and their families about ESRD treatment options, we have developed a prognostic score to predict 6-month mortality in elderly ESRD patients initiating dialysis. Five independent predictors were identified and a point system was constructed: age 75 years or older (2 points), coronary artery disease (2 points), cerebrovascular disease with hemiplegia (2 points), time of nephrology care before dialysis [< 3.0 months (2 points); ≥ 3 to < 12 months (1 point)], serum albumin levels [3.0 - 3.49 g/dL (1 point); < 3.0 g/dL (2 points)]. Model performance was good in both discrimination and internal validation. Before adopting our risk score into practice, our aim is to externally validate this initial predictive model by assessing its performance on a new data set. Methods: We apply the predictive score developed in a cohort of CKD patients, aged 65 years and over who started dialysis between 2009 and 2016, to an independent cohort of ESRD patients, aged 65 years and over who started dialysis between 2017 and 2019, in our Nephrology department. The performance of the prediction equation created in development cohort, was assessed using discrimination and calibration metrics in the validation cohort. Results: Our validation study cohort included 168 individuals, with a mortality rate of 12.5% (n=21) within 6-months of dialysis initiation. Model performance in the validation cohort had an acceptable discrimination [AUC of 0.79; (95% confidence interval, 0.70 to 0.88)]. The Hosmer and Lemeshow goodness-of-fit test was not statistically significant, indicating good calibration of the model (χ2, 5 degrees of freedom = 2.311; P = 0.805). Conclusions: Our predictive simple score based on readily available clinical and laboratory data demonstrates a good performance when externally validated, namely with respect to discrimination and calibration. Model validation is crucial for adequately informing patients and their families about ESRD treatment options and providing a more patient-centered overall approach to care. Before we start general implementation in clinical practice, our score needs further validation in larger patient cohorts.

Background: In December 2019, a new form of coronavirus was identified (COVID-19) and quickly became a worldwide pandemic. Previous data reported a more severe disease in older patients, with high comorbidities, which are common features in hemodialysis patients. Scarce data is available about the clinical presentation and outcomes in this population. For this reason, we aim to report the characteristics of COVID-19 disease in hemodialysis patients admitted to our center. Methods: We retrospectively reviewed all patients on chronic hemodialysis admitted with a laboratory-confirmed COVID-19 infection from March 2nd to May 20th of 2020. Baseline characteristics, clinical, laboratory and radiological presentation were registered and treatment and outcomes Results: Fourteen patients were included, 57% female, with a median age of 81 years old and a high number of comorbidities. Cough and fever were the most common symptoms and lymphocytopenia, increased inflammatory parameters and coagulation dysregulation were frequently registered. Ground-glass opacities were present in each thorax computerized tomography performed. Five patients developed respiratory insufficiency, but none needed invasive ventilation or ICU admission. In a significant proportion, discharge was postponed due to the impossibility of ensuring social isolation. Median viral shedding was 38 days. Discussion and conclusion: Hemodialysis patients who required hospitalization were very old and had multiple comorbidities. Even so, the impaired immune response of this population seems to cause a less severe course of the disease and a longer time of viral shedding. HD units have required a reformulation of their circuits in order to avoid disease spreading.

Rituximab (RTX) is a chimeric anti-CD20 monoclonal antibody that has been associated with delayed pulmonary toxicity. In patients receiving RTX, hypersensitivity pneumonitis, although rare, should be considered in the appropriate clinical and radiographic setting. The authors present a case of hypersensitivity pneumonitis associated with a single dose of RTX treatment in a kidney transplanted patient with acute antibody-mediated rejection.

Background: Many patients with end-stage renal disease start renal replacement therapy in an unplanned manner. The vast majority initiate hemodialysis by a central venous catheter, since its use is more widespread and available. This technique is associated with a high risk of infection and damage of the vascular patrimony associated with the use of central veins. Urgent-start peritoneal dialysis comes as an alternative treatment for selected patients. Case report: A 55-year-old woman with focal segmental glomerulosclerosis presented with a rapid decline of renal function and was given renal replacement therapy counselling and opted for peritoneal dialysis. Her chosen modality was postponed for one month due to early uremic symptoms, followed by hemodialysis start through a central venous catheter. During this period a sepsis due to central venous catheter infection occurred, implying four weeks of intravenous antibiotics. Discussion and Conclusion: Although there has been an increase in the number of publications on urgent-start peritoneal dialysis, showing that this technique has comparable results either to urgent-start hemodialysis and planned-start peritoneal dialysis, there still is some resistance to the use of this modality. Given the importance of this subject, this review aims to describe and summarize the available evidence on urgent-start peritoneal dialysis outcomes. Moreover, specific barriers are addressed. Its use is encouraged in hospitals where peritoneal dialysis is available, as an opportunity to improve chronic kidney disease patient management and transition to dialysis.

RESUMO Introdução: Tem sido sugerido que os níveis de cistatina C são modificados pela obesidade e inflamação. Além disso, a cistatina C tem sido associada a eventos cardiovasculares e desfechos de mortalidade. Objetivo: Estudar a associação da cistatina C com o perfil metabólico e doença cardiovascular de pacientes em diálise peritoneal. Métodos: Os dados coletados incluíram avaliação clínica, laboratorial e de bioimpedância múltipla de 52 pacientes estáveis em diálise peritoneal. A função renal residual mínima foi definida como > 2mL/min/1,73m2. Resultados: A cistatina C sérica não esteve significativamente associada à excreção peritoneal ou urinária. A correlação negativa da cistatina C com a taxa catabólica protéica normalizada (rho -0,33, p = 0,02) e uma tendência de correlação positiva com a gordura corporal relativa (rho 0,27, p = 0,05) não foram independentes da função renal residual. A cistatina C não se associou significativamente à doença cardiovascular (p = 0,28), nem com hemoglobina glicada (p = 0,19) ou proteína C reativa (p = 0,56). No modelo multivariado, idade e diabetes foram os mais fortes preditores de doença cardiovascular (razões de probabilidade 1,09, p = 0,029 e 29,95, p = 0,016, respectivamente) enquanto a gordura corporal relativa se associou negativamente à doença cardiovascular (p = 0,038). A cistatina C não se associou significativamente com doença cardiovascular (p = 0,096), tampouco a função residual mínima (p = 0,756). Conclusão: Neste grupo de pacientes em diálise peritoneal, a cistatina C não se correlacionou com o estado metabólico ou inflamatório, nem com doença cardiovascular, após ajuste para função renal residual.

ABSTRACT Introduction: It has been suggested that cystatin C levels are modified by obesity and inflammation. Furthermore, cystatin C has been associated with cardiovascular events and mortality outcomes. Aim: To study the association of cystatin C with the metabolic profile and cardiovascular disease of peritoneal dialysis patients. Methods: Data collected included clinical, laboratorial, and multifrequency bioimpedance assessment of 52 stable peritoneal dialysis patients. Minimal residual renal function was defined as > 2mL/min/1.73m2. Results: Serum cystatin C was not significantly associated with peritoneal or urinary cystatin C excretion. Negative correlation of cystatin C with normalized protein catabolic rate (rho -0.33, p = 0.02) and a trend towards positive correlation with relative body fat (rho 0.27, p = 0.05) were not independent from residual renal function. Cystatin C was not significantly associated with cardiovascular disease (p = 0.28), nor with glycated hemoglobin (p = 0.19) or c-reactive protein (p = 0.56). In the multivariate model, both age and diabetes were the strongest predictors of cardiovascular disease (odds ratio 1.09, p = 0.029 and odds ratio 29.95, p = 0.016, respectively), while relative body fat was negatively associated with cardiovascular disease (p = 0.038); neither cystatin C (p = 0.096) nor minimal residual renal function (p = 0.756) reached a significant association with cardiovascular disease. Conclusions: In this group of peritoneal dialysis patients, cystatin C did not correlate with the metabolic or inflammatory status, nor cardiovascular disease, after adjustment for residual renal function.

Introduction: ABO incompatibility was considered a barrier to kidney transplant. However, the shortage of available organs for transplantation and the excellent long-term results further establish ABO-incompatible (ABOi) as a safe and effective therapeutic strategy. The aim of the present study was to evaluate the outcomes of ABOi transplantation in terms of graft survival and function, rejection episodes and infections complications. Methods: The authors present a single-center retrospective observational study in a unit with approximately 370 living donor kidney transplants registered. This study includes the analysis of 12 patients who underwent ABOi living donor kidney transplantation between November 2014 and July 2019. Desensitization protocol consisted of intravenous Rituximab 375mg/m2 single dose administration 2 weeks pretransplant. Tacrolimus and Mycophenolate Mofetil were started before transplantation one week and 48 hours respectively. Plasmapheresis was performed to remove anti-A or B antibodies until their titers were <1:8 during the first post-operative week and <1:16 at the second. All kidney recipients of both ABOi grafts received Basiliximab (20mg on days 0 and 4) as antibody induction therapy. Maintenance immunosuppression consisted of Tacrolimus, Mycophenolate Mofetil and corticosteroid. Results: A total of 12 patients were included in the study, 75% male; 43 years (IQR 31-50). The most common blood group mismatch was A to O (n=4; 33%). In the first year, 2 of patients (25%) developed acute rejection. The follow-up time was 17 months (IQR 7-36). Five patients (42%) developed infectious complications. None patients developed cytomegalovirus or BK polyomavirus infections. At the end graft and patient survival were 100%. Conclusion: ABOi kidney transplantation has become a routine procedure. With this approach, about 30% of living donors who were refused in the past can now donate their kidneys and thereby significantly expand the living donor pool. The immunosuppressive protocol of this unit can be considered safe.

RESUMO Introdução: Doença renal crônica (DRC) é fator de risco independente para vários desfechos desfavoráveis, incluindo doença cardiovascular (DCV), particularmente em idosos, o segmento de crescimento mais rápido da população com doença renal terminal (DRT). Portugal tem a maior incidência europeia não-ajustada e a maior prevalência de DRT. Neste artigo caracterizamos uma coorte de idosos com DRC, referenciados para a nefrologia, com particular ênfase para o risco e carga de doença cardiovascular. Métodos: Foram incluídos todos os pacientes com DRC com 65 anos ou mais encaminhados ao nosso departamento em 2012. Os dados basais incluíram: demografia, estágio da DRC, medicação e comorbidades. A taxa de filtração glomerular (TFGe) foi calculada pela fórmula CKD-EPI. Resultados: Metade dos 416 pacientes incluídos foram encaminhados por médicos da atenção primária; sua idade era 77 ± 7 anos; 52% eram homens; a TFGe mediana era de 32 mL /min/1,73 m2. Metade tinha diabetes (DM), 85% dislipidemia, 96% hipertensão; 26% eram fumantes atuais/ antigos; 24% tinham índice de massa corporal > 30 kg/m2. A prevalência de DCV foi de 62%, sendo maior entre pacientes nos estágios 4-5; em diabéticos, aumentou gradualmente com a progressão da DRC (estágio 3a < estágio 3b < estágio 4-5) (39%, 58%, 82%; p < 0,001). Conclusões: A coorte de idosos com DRC apresentava inicialmente maior carga de DCV. A prevalência de DCV foi maior que em outras coortes europeias com DRC. Níveis menores de TFGe foram associados a carga maior de DCV e foram mais pronunciados entre diabéticos, destacando a importância de objetivar estrategicamente a redução do risco cardiovascular nesses pacientes.

ABSTRACT Introduction: Chronic kidney disease (CKD) is an independent risk factor for several unfavorable outcomes including cardiovascular disease (CVD), particularly in the elderly, who represent the most rapidly growing segment of the end-stage kidney disease (ESKD) population. Portugal has the highest European unadjusted incidence and prevalence rates of ESKD. In 2012, we started to follow a cohort of elderly CKD patients, we describe their baseline characteristics, risk profile, and cardiovascular disease burden. Methods: All CKD patients aged 65 years and older referred to our department during 2012 were enrolled. Baseline data included: demographic, CKD stage, medication, comorbid conditions. Estimated glomerular filtration rate (eGFR) was calculated by the CKD-EPI formula. Results: A total of 416 patients, 50% referred by primary care physicians, aged 77 ± 7 years, 52% male, with a median eGFR of 32 mL/min/1.73m2 participated in the study. Fifty percent had diabetes (DM), 85% dyslipidemia, 96% hypertension; 26% were current/former smokers, and 24% had a body mass index > 30 kg/m2. The prevalence of CVD was 62% and higher in stage 4-5 patients; in diabetics, it gradually increased with CKD progression (stage 3a < stage 3b < stage 4-5) (39, 58, 82%; p < 0.001). Conclusions: At baseline, our CKD elderly cohort had a higher burden of CVD. The prevalence of CVD was greater than in other European CKD cohorts. Lower level of eGFR was associated with a greater burden of CVD and was more pronounced in diabetics, highlighting the importance of strategically targeting cardiovascular risk reduction in these patients.

Introduction: Vascular access (VA) for hemodialysis (HD) is the lifeline for End Stage Renal Disease (ESRD) patients. Long-term HD patients often have exhaustion of their venous patrimony for an autologous VA construction and, sometimes, even for a central venous catheter (CVC) placement. Case report: We describe the case of a 43-year-old woman with ESRD due to lupus nephritis, on maintenance HD since 2009. She also had secondary antiphospholipid syndrome and was chronically anticoagulated. Nevertheless, the patient had multiorgan thrombotic events (without sequelae) and several episodes of irreversible thrombosis of arteriovenous fistulas. Her HD course was also marked by multiple severe CVC infections, at different locations; a hemoperitoneum during cholecystectomy, and an immediate thrombosis of the renal artery of a kidney transplant. She was admitted to our hospital after an irreversible dysfunction of a right jugular CVC, with documentation of thrombosis of the superior and inferior vena cava. Exhaustion of the venous patrimony for HD was assumed and it was decided to make an arterio-arterial graft (AAG) of early cannulation. The first cannulation of the AAG was performed two days after surgical intervention, with no complications. The patient performed a twelve hour per week HD treatment with good efficiency. Conclusion: AAG is an alternative for HD patients who have exhausted all their venous patrimony and it can be considered prior to the placement of a CVC as their sole remaining vascular access.