ABSTRACT Introduction: Acute kidney injury (AKI) is a common postoperative complication (postoperative AKI, [PO-AKI]), occurring in up to 35% of non-cardiac surgery. Some biomarkers have shown value in early identification but are underused in clinical practice due to their high cost. The SPARK score and the hemoglobin-to-red cell distribution width ratio (Hb/RDW) have emerged as accessible alternatives for predicting PO-AKI. Objective: To evaluate studies on SPARK predictors and hematological biomarkers for risk stratification of PO-AKI in non-cardiac surgery. Methods: An integrative review was conducted across four databases (PubMed/MEDLINE, LILACS, Embase, and Web of Science), covering publications between 2019 and 2025 in Portuguese and English. Studies including adults undergoing non-cardiac surgery were included. The selection process was documented using a PRISMA 2020 flow diagram. Results: Six studies were included. The SPARK score showed an AUC ranging from 0.69 to 0.81 in external validations, with superior performance in modified models for specific populations. The Hb/RDW index demonstrated good accuracy (AUC 0.714; sensitivity 72.7%; specificity 70.8%) in elderly orthopedic patients, with lower values associated with increased risk of PO-AKI. Discussion: The effectiveness of SPARK depends on the population profile, highlighting the importance of external validation and contextual adjustments. Hb, RDW, and the Hb/RDW ratio appear to be promising tools to complement SPARK. Conclusion: The application of SPARK may be limited in different contexts. Simple biomarkers such as Hb, RDW, and Hb/RDW show good predictive potential and may improve the early identification of patients at risk for PO-AKI.
Abstract Introduction: Postnatal growth profile is believed to have an impact on the risk of later obesity and of cardiovascular and kidney disease. We aimed to study the association between different trajectories of weight gain during infancy and early childhood and the renal function in prepubertal children. Methods: Longitudinal study of 1,004 children aged 7–9 years, divided into four groups of weight gain trajectories from birth to 6 years (I: eutrophic/reference; II: early-onset persistent accelerated weight gain; III: childhood-onset accelerated weight gain; and IV: early transient weight gain). Glomerular filtration rate (GFR) was estimated by several formulas using serum creatinine (Cr) and/or cystatin C (CysC), and by 24-hour creatinine clearance (CrCl). Results: Individuals in trajectory I presented the lowest Cr and CysC and the highest estimated GFR (eGFR) values, while trajectory II included those with the lowest eGFR, estimated by the Filler and Le Bricon formulas. Trajectory I individuals presented the lowest absolute CrCl values, while those in trajectory II presented the highest values. In multivariate linear regression models adjusted for age, sex, birth weight-for-gestational-age category, blood pressure, and current body mass index, trajectory III was associated with an eGFR that was 2.68 to 3.75 mL/min/1.73 m2 lower than that of trajectory I in the two models based on CysC. Conclusions: Children with early-onset persistent or childhood-onset accelerated weight gain presented significantly lower eGFR, which supports the influence of childhood growth patterns on later kidney function.
Abstract Introduction: Chronic kidney disease imposes a high clinical and economic burden on the Brazilian Unified Health System, and kidney transplantation represents one of the best therapeutic choices for selected patients. Objective: To describe trends in living-donor (LD) kidney transplantation in Brazil (2010–2023), analyzing the donor–recipient relationship and the operational stock-to-annual production ratio on the waiting list, as well as to compare hospital indicators and estimated patient and graft survival between LD and deceased-donor (DD) kidney transplants. Methods: This descriptive time-series study used aggregated, publicly available data. Results: The waiting list increased by 15% (from 33,253 to 38,258), and the total number of transplants rose by 29% (from 4,656 to 6,047). Data showed an increase in deceased-donor transplants (from 3,001 to 5,189) and a decrease in LD transplants (from 1,655 to 858), with the LD share declining from 35.55% to 14.19% and the per-million-population rate falling from 8.8 to 4.2. Among LD, there was a relative decrease in related donors (from 82.80% to 71.21%), a relative increase in unrelated spouse donors (from 10.57% to 18.65%), and a relative increase in other unrelated donors (from 6.64% to 10.14%). In descriptive comparisons, LD transplantation showed higher published patient and graft survival estimates and more favorable hospital indicators, including lower in-hospital mortality, shorter length of stay, and lower mean hospital admission authorization values. Conclusion: The findings suggest the relevance of integrated strategies to sustain deceased-donor procurement and strengthen living-donor kidney transplantation. However, comparisons between donor types were descriptive and should not be interpreted as causal.
Despite substantial improvements in short-term outcomes after kidney transplantation, important unmet clinical needs persist. These include expanding transplant access for highly sensitized candidates, mitigating the short- and long-term consequences of ischemia-reperfusion injury, preventing acute rejection while preserving allograft function, minimizing off-target toxicities associated with calcineurin inhibitor-based immunosuppressive regimens, improving adherence to long-term immunosuppressive therapy, and developing effective treatments for late antibody-mediated rejection. A growing pipeline of novel therapeutic agents aims to address these challenges by targeting key immunologic and injury pathways that contribute to allograft dysfunction and failure. In this review, we examine emerging pharmacologic strategies currently undergoing clinical evaluation in these domains and critically assess their potential to improve long-term graft survival and patient outcomes. We also discuss the key considerations and priorities that should inform future clinical investigation in kidney transplantation.
INTRODUCTION:Chronic kidney disease (CKD) is associated with a chronic low-grade inflammatory state, which may be influenced by dietary patterns. The Dietary Inflammatory Index (DII) is a validated tool used to estimate the inflammatory potential of the diet. OBJECTIVE:To evaluate the dietary inflammatory potential in patients with CKD undergoing conservative treatment and its association with anthropometric and cardiovascular risk markers. METHODS:A cross-sectional observational study was conducted in adult patients diagnosed with stage 3-5 CKD under conservative management. Dietary intake was assessed using two non-consecutive 24-hour dietary recalls, and DII scores were calculated based on 36 dietary parameters. Anthropometric and cardiovascular risk indicators were evaluated, including body mass index (BMI), triceps skinfold thickness (TSFT), arm muscle area (AMA), waist-to-height ratio (WHtR), Castelli indices, and the conicity index (CI). Multivariate linear regression models were adjusted for age, sex, and estimated glomerular filtration rate (eGFR). RESULTS:A total of 51 patients were included, with a median age of 71 years (IQR, 56-80), and 56.9% were female. The median DII score was 2.90 (IQR, 2.29-3.74), indicating a predominantly pro-inflammatory dietary profile. Higher DII scores were associated with higher conicity index values (β = 0.368; p = 0.010). No statistically significant associations were observed between the DII and other anthropometric, biochemical, or cardiovascular risk markers. CONCLUSION:Patients with CKD under conservative treatment exhibited predominantly pro-inflammatory dietary patterns. Higher DII scores were associated with greater central adiposity.
INTRODUCTION:Glomerulopathies are the third leading cause of dialysis-dependent chronic kidney disease (CKD) in Brazil and are most commonly diagnosed by kidney biopsy; however, data regarding the prevalence and epidemiological characteristics of glomerulopathies are scarce. The present article reports the results of an epidemiological survey of glomerular diseases in Northeast Brazil. METHODS:This retrospective study, based on kidney biopsy data from all states in Northeast Brazil (2008-2024), was conducted at a reference center for kidney pathology. Demographic data (age, sex, and ethnicity), clinical history, indications for kidney biopsy, and histopathological diagnoses were collected. Frequencies are presented as percentages, along with maps and charts. RESULTS:Data from 2,661 patients (median age, 31 years [interquartile range, 19-45 years]) were included in the study, with a slight female predominance (n = 1,533 [57.6%]). The indication for biopsy was identified in 85.9% of cases, with nephrotic syndrome being the most common (n = 1,075 [40.39%]). Lupus nephritis (LN) was the most frequent etiology (n = 876 [32.9%]), followed by focal segmental glomerulosclerosis (FSGS; n = 455 [17.1%]). The most common diagnosis among older adults was membranous nephropathy (n = 43 [18.8%]), whereas the most prevalent diagnosis among children was FSGS (n = 105 [24.5%]). CONCLUSION:The profile of glomerulopathies reflects not only local biopsy indications but also the heterogeneity of the population of Northeast Brazil and its particular ethnic and socioeconomic characteristics. Glomerulopathies, such as LN, accounted for the majority of cases, indicating the influence of ancestral factors in this region.
INTRODUCTION:Hemodialysis is one of the most water-intensive and waste-generating therapies in health care, yet its environmental impact remains poorly documented in low- and middle-income countries. This study aimed to estimate water consumption and solid waste generation in a hemodialysis unit in northeastern Brazil that reprocesses dialyzers, comparing the observed scenario with an estimated counterfactual single-use scenario. METHODS:This was a single-center, retrospective observational study. Aggregate institutional data on water consumption, supply procurement, and waste mass were analyzed over a 12-month period. An estimated counterfactual single-use scenario was constructed using mathematical projections, assuming one new dialyzer per session. Carbon dioxide equivalent (CO2-eq) emissions were estimated using an emission factor for the incineration of clinical waste. RESULTS:A total of 34,759 hemodialysis sessions were performed, with a mean of 223 patients/month. Total water consumption was 14.9 million liters, corresponding to 429 L/session (2.3% attributed to reprocessing). Solid waste generation was 30.9 t (0.89 kg/session), consisting of 21.6% contaminated waste, 51.5% solution containers/bottles, and 26.8% cardboard. Of all plastic waste, 70.4% was recycled and 29.6% was incinerated. In the counterfactual single-use scenario, waste generation was estimated to increase by 78.7%, incinerated plastics by 312%, and associated emissions by an additional 37.5 t of CO2-eq. CONCLUSION:The comparison of the two scenarios suggests that dialyzer reprocessing had a marginal effect on water consumption and reduced waste generation and associated emissions. These comparisons should be interpreted as environmental estimates; they do not allow causal inferences or universal recommendations.
Abstract Background: Chronic kidney disease (CKD) and acute kidney injury (AKI) affect over 850 million individuals worldwide, with diagnosis and management heavily dependent on laboratory biomarkers. Reliable assessment of kidney biomarkers is therefore essential. External Quality Assessment (EQA) plays a critical role in ensuring the accuracy and comparability of results across laboratories. Methods: We retrospectively analyzed EQA data from a Brazilian proficiency testing provider (January 2009–March 2024). Reported results for serum creatinine, urinary creatinine, urinary albumin, and total urinary proteins were evaluated. Coefficients of variation (CVs) and adequacy percentages (%Adequacy) were compared across methods using the Kruskal–Wallis test. Trends were assessed with the Mann–Kendall test. Results: For serum and urinary creatinine, amidinohydrolase/oxidase methods consistently showed the lowest CVs (~3–4.5%) compared with Jaffé-based methods. For urinary albumin, turbidimetry demonstrated superior performance (~5.0% CV), while for total urinary proteins, benzethonium chloride methods yielded the best results (~5.0% CV). Across all biomarkers, CVs decreased and %Adequacy increased significantly over the 15-year period, particularly at clinically relevant concentrations. Nevertheless, Jaffé-based creatinine methods remained predominant despite their well-documented specificity limitations. Conclusion: Over 15 years, participant laboratories improved the precision and adequacy of kidney biomarker measurements in EQA programs. However, persistent reliance on outdated Jaffé-based creatinine methods compromises standardization and clinical reliability. Adoption of more specific methods and participation in clinically relevant EQA programs are essential to further strengthen laboratory quality and patient safety.
ABSTRACT Introduction: Pediatric rapidly progressive glomerulonephritis (RPGN) encompasses heterogeneous serology-based subtypes, including anti-glomerular basement membrane (anti-GBM), immune-complex-associated, and ANCA-associated (pauci-immune) RPGN. Although these subtypes differ in their underlying immune mechanisms, their ability to predict early renal recovery in children remains uncertain. This study aimed to evaluate the association between serology-based RPGN subtypes and early changes in renal function and tubular injury markers. Methods: This prospective cohort study included 30 children with newly diagnosed RPGN treated at Dr. Soetomo General Hospital. Patients were classified into anti-GBM, immune-complex-associated, or ANCA-associated RPGN based exclusively on serologic criteria. Estimated glomerular filtration rate (eGFR) and serum kidney injury molecule-1 (KIM-1) were measured at baseline and at 3 months after induction therapy. Primary outcomes were changes in eGFR (ΔeGFR) and serum KIM-1 (ΔKIM-1). Differences among subtypes were assessed using multivariate analysis of variance. Results: Of the 30 patients, 67% had immune-complex-associated RPGN, 20% had ANCA-associated RPGN, and 13% exhibited anti-GBM disease. The median age was 15 years. No statistically significant differences in ΔeGFR or ΔKIM-1 were observed among subtypes (MANOVA, p = 0.506), although numerical improvements varied across groups. Conclusion: Serology-based RPGN subtype was not associated with early improvement in glomerular filtration or reduction in tubular injury markers in pediatric RPGN. Early renal recovery may be influenced more by baseline disease severity and therapeutic responsiveness than by serologic subtype classification alone.
Abstract Incremental dialysis, applicable to both hemodialysis (HD) and peritoneal dialysis (PD), is an individualized approach. It consists of offering a dialysis dose adjusted to the patient’s residual renal function (RRF) in order to achieve the same clinical outcomes observed with full doses, while improving quality of life and reducing exposure to the risks associated with the dialysis procedure. This Position Statement of the Brazilian Society of Nephrology (SBN) aims to present recommendations on eligibility criteria, prescription, monitoring, and safe implementation, as well as to report the clinical results already described with this approach. Eligibility includes a residual diuresis ≥ 500 mL/24h in HD or ≥ 100 mL/24h in PD and/or a urea clearance (Kru) ≥ 2.0 mL/min/1.73 m2, as well as clinical stability and adequate volume and metabolic control. Monitoring with regular reassessment of RRF is recommended. Indicators for dialysis dose intensification include hypervolemia, uremic symptoms, worsening of nutritional status, hyperkalemia, hyperphosphatemia, refractory metabolic acidosis, and laboratory findings of subdialysis. The implementation of incremental dialysis requires well-defined institutional protocols, systematic education of patients and families, a properly trained multidisciplinary team, and a shared decision-making process. Scientific evidence suggests that incremental dialysis is safe and effective, attenuating the loss of RRF, and can reduce hospitalizations, while maintaining or improving quality of life, without increasing mortality. Additionally, it may contribute to cost reduction and greater sustainability of the healthcare system, and should be considered an integral part of the contemporary therapeutic armamentarium.
ABSTRACT Introduction: The transcription factor BTB and CNC homology 1 (Bach1) represses the nuclear factor erythroid 2–related factor 2 (Nrf2), which controls antioxidant gene expression, and its role in chronic kidney disease (CKD) remains unclear. Methods: CKD was induced by 5/6 nephrectomy in rats. Kidney fibrosis and oxidative stress markers were measured. The gene expression of Nrf2, Bach1, and nuclear factor kappa B (NF-κB) was assessed. Results: CKD increased oxidative stress markers in plasma, kidney, and heart, as well as promoted kidney fibrosis. Moreover, CKD reduced cardiac Nrf2 expression. However, Bach1, Nrf2, and NF-κB remained unchanged in the kidney. Conclusion: CKD did not modulate Bach1 mRNA levels in the kidneys of 5/6 nephrectomized rats.
ABSTRACT Acute kidney injury (AKI), a widespread severe acute condition caused by several factors and characterized by a rapid decline in renal function over a short time, is associated with high incidence and mortality rates worldwide. Investigating AKI signaling pathways is crucial for elucidating its pathogenesis, optimizing diagnostic and therapeutic approaches, and developing novel therapeutic agents. This article comprehensively examines AKI pathophysiological mechanisms, apoptosis-related signaling pathways, and inflammatory response pathways. It analyzes clinical signaling pathways associated with epidemiology, diagnostic technologies, and therapeutic strategies, explores advancements in novel biomarker applications, drug development, and gene editing technologies, and discusses current hot topics and controversies. The study further outlines future research trends, personalized treatment prospects, and potential challenges and opportunities, aiming to provide comprehensive insights into AKI signaling pathway research and lay the foundation for further exploration in related fields.
Abstract Introduction: Information about the clinical and epidemiological profile of children and adolescents undergoing chronic dialysis in Brazil is limited. Objective: To describe the clinical and epidemiological characteristics of the pediatric population undergoing chronic outpatient dialysis treatment in a capital city in Northeastern Brazil. Methods: This is a descriptive, observational, and retrospective study whose population consisted of all children and adolescents undergoing chronic outpatient dialysis treatment in São Luís, capital of the state of Maranhão, Brazil, in 2023. Results: Thirty-two children and adolescents with chronic kidney disease (CKD) were undergoing dialysis treatment during this period, the majority (56.25%) being male. The mean age was 11.31 years (± 3.56). Regarding ethnicity, non-white individuals predominated (71.9%). The renal replacement therapy (RRT) modality was exclusively hemodialysis (HD), and the most commonly used vascular access at the end of the follow-up period was arteriovenous fistula (AVF) (56.2%). Regarding the underlying disease, 35% had an unknown etiology. There were nine transplants during the period, all from deceased donors. At that time, there was virtually universal access to erythropoiesis-stimulating agents and drugs for the prevention and treatment of bone mineral metabolic disorders. Conclusion: The high rate of unknown underlying disease and the exclusive use of HD as the RRT modality, rather than peritoneal dialysis, reflect diagnostic, therapeutic, and structural challenges. This scenario highlights the need for better planning of public policies aimed at managing pediatric CKD in the region.
