A paradigm shift in the treatment of end-stage kidney disease (ESKD) is urgently needed. New ESKD policies should include integrated and person-centered care that focuses on the individual's preferences, needs, and values for health care. Based on the example of Portugal, a country with a very high number of prevalent in-center hemodialysis patients, the authors reflect on the past and present of ESKD treatment worldwide, trying to summarize the conceptual changes in the efficiency and equity of ESKD treatment. An optimal approach in ESKD management should consider all options for renal replacement therapy, including a comprehensive conservative approach, of which the incidence and prevalence should be reported on a regular basis for each country and for Europe. An active holistic care to patients with ESKD suffering from severe illness or near the end of life, without dialysis or kidney transplant, is still frequently ignored as an option. In cases of frail or very old individuals or in those with multiple co-morbidities or in poor physical condition, conservative treatment should be considered as a firstline option. A proposal of ESKD treatment following the model of classification of CKD is presented. Up-to-date regulations from national health authorities are needed, especially on the priority policy of supportive/palliative care in non-malignant disease, including ESKD.

Abstract Hyponatremia, defined as a serum sodium concentration <135 mmol/l, is the most common water-electrolyte imbalance encountered in clinical practice. It can lead to a wide spectrum of clinical symptoms, from mild to severe or even life threatening, and is associated with increased mortality, morbidity and length of hospital stay. Despite this, the management of hyponatremia patients remains problematic. The prevalence of hyponatremia in a wide variety of conditions and the fact that hyponatremia is managed by clinicians with a broad variety of backgrounds have fostered diverse institution- and specialty-based approaches to diagnosis and treatment. To obtain a common and holistic view, the European Society of Intensive Care Medicine (ESICM), the European Society of Endocrinology (ESE) and the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA), represented by European Renal Best Practice (ERBP), have developed clinical practice guidelines on the diagnostic approach and treatment of hyponatremia as a joint venture of 3 societies representing specialists with a natural interest in hyponatremia. In addition to a rigorous approach to the methodology and evaluation of the evidence, the document focuses on patient-positive outcomes and on providing a useful tool for clinicians involved in everyday practice. In this article, we present an abridged version of the recommendations and suggestions for the diagnosis and treatment of hyponatremia extracted from the full guide.

Resumen La hiponatremia se define como una concentración sérica de sodio <135 mmol/L y es el trastorno hidroelectrolítico más frecuente en la práctica clínica. La hiponatremia puede causar un amplio espectro de síntomas clínicos, desde sutiles hasta graves o incluso mortales, y se asocia con aumento de la morbimortalidad y prolongación de la estancia hospitalaria. A pesar de ello, el manejo de los pacientes con hiponatremia sigue siendo problemático. La prevalencia de hiponatremia en enfermedades muy diferentes y su manejo por muy diversos especialistas han fomentado la existencia de protocolos de diagnóstico y tratamiento muy diversos, que varían con la especialidad y la institución. La Sociedad Europea de Medicina Intensiva (ESICM), la Sociedad Europea de Endocrinología (ESE) y la Asociación Renal Europea-Asociación Europea de Diálisis y Trasplante (ERA-EDTA), representada por la European Renal Best Practices (ERBP), han desarrollado la guía de práctica clínica sobre el enfoque diagnóstico y tratamiento de la hiponatremia como una empresa conjunta de las 3 sociedades que representan a los especialistas con un interés natural en la hiponatremia, a fin de ofrecer una visión común y holística del abordaje del problema. Además de ofrecer un enfoque riguroso en la metodología y la evaluación de la evidencia, el documento está centrado en resultados importantes para el paciente y en facilitar una herramienta útil para los médicos en la práctica clínica cotidiana. Presentamos ahora una versión abreviada de las recomendaciones y sugerencias sobre el diagnóstico y el tratamiento de la hiponatremia recogidas en la guía completa.

Introdução: Estudos experimentais indicam que o indoxil sulfato (IS), uma toxina urêmica ligada à proteína, pode estar envolvido no desenvolvimento da osteodistrofia renal. Objetivo: Avaliar a associação entre os níveis séricos de IS e parâmetros bioquímicos do metabolismo mineral e da histomorfometria óssea em uma coorte de pacientes com doença renal crônica (DRC) pré-diálise. Métodos: Análise post-hoc de um estudo que avaliou a associação entre calcificação coronariana e histomorfometria óssea em 49 pacientes (idade: 52 ± 10 anos; 67% sexo masculino; taxa de filtração glomerular estimada: 36 ± 17 ml/min). Os níveis séricos de IS foram dosados. Resultados: Pacientes com DRC estágio 2 e 3 apresentaram uma taxa de formação óssea baixa. Pacientes com DRC estágio 4 e 5 apresentaram volume osteoide, superfícies osteoblástica e osteoclástica, volume de fibrose e taxa de formação óssea significativamente maiores e intervalo de mineralização significativamente menor que os pacientes com DRC estágio 2 e 3. Os níveis séricos de IS associaram-se positivamente com a taxa de formação óssea, volume osteoide, superfície osteoblástica e volume de fibrose. A análise de regressão multivariada identificou que o IS é um fator independente determinante da superfície osteoblástica e fibrose. Uma tendência similar foi observada para a taxa de formação óssea. Conclusão: Nosso estudo sugere que, na DRC pré-dialítica, o IS correlaciona-se positivamente com a formação óssea.

Introduction: Experimental studies have suggested that indoxyl sulfate (IS), a protein-bound uremic toxin, may be involved in the development of renal osteodystrophy. Objective: evaluate the association between IS levels and biochemical parameters related to mineral metabolism and bone histomorphometry in a cohort of pre-dialysis chronic kidney disease (CKD) patients. Methods: This is a post-hoc analysis of an observational study evaluating the association between coronary calcification and bone biopsy findings in 49 patients (age: 52 ± 10 years; 67% male; estimated glomerular filtration rate: 36 ± 17 ml/min). Serum levels of IS were measured. Results: Patients at CKD stages 2 and 3 presented remarkably low bone formation rate. Patients at CKD stages 4 and 5 presented significantly higher osteoid volume, osteoblast and osteoclast surface, bone fibrosis volume and bone formation rate and a lower mineralization lag time than CKD stage 2 and 3 patients. We observed a positive association between IS levels on one hand and the bone formation rate, osteoid volume, osteoblast surface and bone fibrosis volume on the other. Multivariate regression models confirmed that the associations between IS levels and osteoblast surface and bone fibrosis volume were both independent of demographic and biochemical characteristics of the study population. A similar trend was observed for the bone formation rate. Conclusion: Our findings demonstrated that IS is positively associated with bone formation rate in pre-dialysis CKD patients.

The purpose of this Clinical Practice Guideline is to provide guidance on evaluation of the kidney donor and transplant recipient as well as on the management of the recipient in the perioperative period. It is designed to provide information and aid decision-making. It is not intended to define a standard of care, and should neither be construed as one nor should it be interpreted as prescribing an exclusive course of management. The original version of this guideline was published in Nephrology, Dialysis and Transplantation and this current version is a reduced article aiming to disseminate the guideline into Spanish-speaking countries and transplant communities.

El objetivo de esta Guía de Práctica Clínica es ofrecer orientación para la evaluación tanto del donante como del receptor del trasplante de riñón y para el manejo del receptor durante el periodo perioperatorio. Ha sido diseñada para informar y asistir en la toma de decisiones. En ningún caso pretende definir una norma asistencial ni su carácter debe concebirse como tal ni interpretarse como prescriptivo de un manejo exclusivo. La versión original de esta guía fue publicada en la revista Nephrology, Dialysis and Transplantation. Esta versión reducida pretende colaborar en la divulgación de esta guía en los países y comunidades trasplantadoras hispanohablantes.