INTRODUCTION: Heart failure (HF) is highly prevalent with substantial impact on morbidity and mortality. In chronic kidney disease (CKD), it acts both as a risk factor and a complication. This study aims to elucidate the prevalence of HF according to ejection fraction (EF) in pre-dialysis CKD patients and its impact on mortality and renal replacement therapy (RRT) initiation.METHODS: Retrospective cohort study including all stages CKD patients followed at an out-patient Nephrology clinic for seven years. HF diagnosis was established based on clinical assessment and echocardiogram. Univariate and multivariate cox-regression analysis were used.RESULTS: A total of 3008 patients with a mean age of 68.2 ± 15.9 years were enrolled in the study, of which 769 (25.5%) had an HF diagnosis - 41.5% preserved EF, 11% mildly reduced EF; 15.2% reduced EF and 32.2% with unknown EF. Mean follow-up time was 3.21±1.97 years, during which 24.8% of patients died and 8.7% started RRT. In multivariate analysis, HF led to an increased risk of all-cause mortality (HR 1.8; 95% CI 1.5–2.3; p<0.001) and RRT initiation (HR 1.4; 95% CI 1.0-2.0, p=0.05), with increasing risks across EF categories.CONCLUSION: HF worsens outcomes in CKD, conferring higher mortality across all HF subtypes, particularly in the reduced EF subgroup. The higher mortality in preserved EF patients underscores the importance of a correct clinical assessment and modifying treatment implementation. Despite the study's limitations, this work holds significance as it highlights the importance of the establishment of HF classification as it influences prognosis.

A doença renal crónica representa um problema de saúde pública significativo, afetando cerca de 9,8% da população adulta em Portugal. Pese embora este número, o diagnóstico precoce desta doença nos grupos de alto risco é reduzido. Apesar de serem apenas dois os parâmetros cruciais para o seu diagnóstico – a taxa de filtração glomerular estimada (TFGe) e a albuminúria – em Portugal, mais de 50% dos doentes em estádio 3 - 5 não foram alvo de avaliação concomitante da TFGe e albuminúria. A falta de implementação destas duas métricas em simultâneo, leva à avaliação inadequada da população em risco. Um grupo de trabalho composto por 17 peritos portugueses nas principais especialidades médicas envolvidas na gestão da doença renal crónica (Nefrologia, Medicina Geral e Familiar) e em Patologia Clínica/Análises Clínicas (representantes dos principais laboratórios nacionais) reuniu-se para criar um documento de orientações práticas que visa padronizar os procedimentos de prescrição, determinação, emissão de resultados e interpretação dos parâmetros de diagnóstico (albuminúria e TFGe baseada na creatinina sérica) da doença renal crónica em Portugal, baseando-se na prática clínica, conhecimento científico e recomendações internacionais. Este consenso nacional entre os principais intervenientes no processo de rastreio e diagnóstico, culminou na elaboração de quatro orientações práticas que irão permitir fornecer de forma consistente a TFGe e albuminúria, independentemente da especialidade médica do médico assistente, laboratório de análises ou localização geográfica. Além disso, com este esforço coletivo, os peritos pretendem sensibilizar as autoridades nacionais para a redação de novas normas de orientação clínica, fundamentadas em evidência científica e na prática clínica, para abordar a subavaliação da albuminúria e da TFGe na gestão desta doença.

Following publication of the original article, the authors identified an error in the content. The corrected text is presented in the PDF. The original article has also been corrected. Chronic kidney disease represents a significant public health issue, affecting approximately 9.8% of the adult population in Portugal. Despite this figure, early diagnosis of this disease in high-risk groups remains limited. Although only two parameters are essential for its diagnosis – estimated glomerular filtration rate (eGFR) and albuminuria – in Portugal, over 50% of stage 3 - 5 patients have not undergone simultaneous assessment of eGFR and albuminuria. The insufficient implementation of the simultaneous assessment of these two metrics results in an inadequate evaluation of high-risk populations. A task force of 17 Portuguese experts from the main medical specialties involved in chronic kidney disease management (Nephrology and Family Medicine) and in Clinical Pathology/Laboratory Medicine (representatives of major national laboratories) convened to develop guidelines aimed at standardizing procedures for the prescribing, determination, reporting, and interpretation of diagnostic parameters (albuminuria and eGFR based on serum creatinine) in Portugal. This effort is based on clinical practice, scientific knowledge, and international recommendations. This national consensus among the key stakeholders in the chronic kidney disease screening and diagnosis process culminated in the development of four practical guidelines. These guidelines will enable the consistent provision of eGFR and albuminuria measurements, regardless of the attending physician’s medical specialty, the laboratory, or geographic location. Additionally, through this collective effort, experts want to raise awareness among national authorities to the need of developing new guidelines, based on scientific evidence and clinical practice, to address the underassessment of albuminuria and eGFR in this disease’s management.

Introdução: A doença renal crónica é a doença crónica com maior crescimento de prevalência, e uma das maiores causas de mortalidade global de acordo com o Global Burden of Disease Collaboration. O presente estudo teve como objetivo projetar a evolução desta doença em pessoas com diabetes, de modo a quantificar os custos e consequências no contexto português. Tal foi conseguido através do desenvolvimento e parametrização de um modelo analítico refletindo a epidemiologia da doença renal crónica e integrando os vários estádios de progressão da doença. Métodos: Foi utilizado um modelo populacional de coorte com uma mecânica de Markov, onde pessoas com diabetes e doença renal crónica foram seguidas ao longo de 50 anos, em ciclos anuais, sendo registada a sua progressão através das diferentes categorias de risco da doença renal crónica. O modelo considerou a progressão natural da doença renal crónica através de 18 categorias de risco baseados na matriz de estadiamento de KDIGO, bem como a probabilidade de os doentes receberem terapêutica de substituição renal, designadamente, diálise e transplantação renal e a probabilidade de morte. A cada estádio estão associados um custo anual e um ponderador de incapacidade, pelo que o modelo permitiu estimar a sobrevivência, os anos de vida perdidos por incapacidade (years lived with disability), e os custos incorridos ao longo da vida, para a totalidade da população e para doentes em diferentes categorias de risco. Resultados: Durante o tempo total de evolução da coorte, o modelo estimou, para a população total com doença renal crónica e diabetes, uma sobrevivência média de 8,62 anos, com 0,59 anos perdidos por incapacidade, e um custo médio lifetime de €24 613. Estes valores correspondem a mais de 410 mil anos de vida perdidos por incapacidade e um custo total, ao longo da vida, de 17,0 mil milhões de euros. A análise por nível de risco demonstra que a progressão da doença renal crónica está associada a menor sobrevivência, mais anos perdidos por incapacidade e maiores custos. Conclusão: Os resultados deste estudo caracterizam a progressão natural da doença renal crónica em pessoas com diabetes mellitus tipo 2 bem como os custos e consequências associados no contexto nacional. Sendo a diabetes mellitus tipo 2 um fator de risco da doença renal crónica, é expectável que nas próximas décadas o impacto real seja maior do que o estimado. A análise por nível de risco permite verificar que a progressão da doença está associada a piores resultados.

Background:Chronic kidney disease (CKD) is a global health concern associated with increased cardiovascular risks. In Portugal, the high burden of CKD highlights the urgent need for early detection strategies. The primary aim of this study was to assess the presence of albuminuria in the Portuguese general population while raising awareness of CKD. Methods:An epidemiological, cross-sectional study screened 601 individuals for albuminuria using urine test strips, employing a door-to-door approach across the five regions of mainland Portugal (screening study), with 592 valid results included in the final analysis. In parallel, an awareness campaign distributed 17 000 urine test strips, with 704 participants submitting their results through an online platform (awareness study). Results:The screening occurred in a healthy population, with >70% (screening study) and >87% (awareness study) of the individuals reporting no known personal health history. The presence of albuminuria was detected in 5.1% of the screening study population and 3.4% of the awareness study participants. In both studies, significant associations were found between albuminuria and risk factors, such as age, education level, CKD and non-steroidal anti-inflammatory drug use. Regional disparities were also observed. In the screening study, multivariate analysis identified education level (P = .011), CKD (P < .0001) and autoimmune diseases (P = .009) as independent predictors of albuminuria. Conclusions:These findings highlight albuminuria as a critical early marker for CKD and cardiovascular risks. The results support the need for targeted screening and public health initiatives, particularly in high-risk and younger populations.

Abstract Background and Aims The outbreak of coronavirus disease 2019 (COVID-19) pandemic, which originated in December 2019, had a huge impact on healthcare worldwide. Numerous studies have reported alterations in kidney function among hospitalized patients with COVID-19, such as hematuria, proteinuria, and acute kidney injury (AKI). Histopathology exams in autopsies have identified various potential causes for the presence of AKI in these patients, with reports linking AKI to unfavorable outcomes across multiple countries. However, additional data concerning hospitalized COVID patients in Portugal are essential to further understand this aspect. Method Retrospective cohort study enrolling adult patients, who attended the Emergency Department and recorded positive polymerase chain reaction (PCR) results for SARS-CoV-2 from January 1 to January 31, 2021. AKI was diagnosed using the Kidney Disease Improving Global Outcome (KDIGO) classification based on serum creatinine (sCr) criteria and using a background creatinine available in the patient record. We performed an analysis of incidence, lethality, and possible risk factors of AKI in COVID-19 patients. Results The study encompassed a cohort of 239 patients, of whom 62 (25.94%) received a diagnosis of Acute Kidney Injury (AKI) based on KDIGO criteria. Within this subgroup, the average age was 77.65 years (±12.07), with a total of 29 male patients (46.78%). Notably, 30 deaths (48.39%) occurred during the hospital stay in this group. Regarding the AKI classification, 39 patients (62.9%) were classified as KDIGO-AKI stage 1, 14 patients (22.58%) as stage 2, and 9 patients (14.52%) as stage 3. Regarding the timing of the diagnosis of AKI, 54 (87%) occurred in the moment of admission, 7 patients (11.3%) were diagnosed within the first 48 hours and a solitary case (1.6%) was diagnosed after 7 days of hospitalization. In the non-AKI group, the mean age was 69.86 years (±15.95), and approximately 55% were male. Within this group, 49 deaths (27.7%) were recorded during hospitalization. Significantly higher mortality rates were observed in the AKI group, demonstrating a statistically significant difference (p < 0.01) and a relative risk of 1.75 or mortality during hospitalization for AKI patients. Furthermore, the duration of hospitalization was notably prolonged in the AKI group (p < 0.01), with a disparity of approximately three days. Individuals who developed AKI exhibited lower scores on the Barthel-dependence scale, indicative of higher dependence (p < 0.01), and were significantly older (p < 0.01) comparing with the ones that did not develop acute kidney injury. Additionally, it was remarkable that the leukocyte count at admission was more elevated in the AKI group (p = 0.03) compared to non-AKI patients with a difference of approximately 1.62×109/L. Conclusion Respiratory infections, including COVID-19, frequently lead to emergency department admissions and hospitalizations. This study validates an elevated prevalence of acute kidney injury (AKI) both at admission and during the hospital stay in such cases. The presence of AKI is linked to adverse outcomes, including mortality and extended hospital stays, underscoring the critical importance of promptly diagnosing AKI. Larger-scale studies are warranted in this field to enhance our understanding of this entity and therefore improve the outcomes related to this prevalent condition.

Low muscle mass quantity and quality (myosteatosis) can be evaluated by computed tomography (CT) by measuring skeletal muscle area and muscular attenuation, respectively, at the third lumbar vertebra. We aimed to define cut-off points of skeletal muscle area and muscular attenuation to predict mortality in non-dialysis chronic kidney disease (CKD) patients. We conducted a retrospective study including non-dialysis CKD patients over two years, who underwent an opportunistic computed tomography within a two year period, and for whom creatinine was measured within 90 days of CT. Skeletal muscle area was normalized for stature to calculate the skeletal muscle index. Area under the receiver operating characteristic (AuROC) curve and Youden’s index were used, to identify the cut-point, separately according to sex. One hundred sixty-seven patients (50.9

Abstract Background and Aims Skeletal muscle composition disturbances, like sarcopenia and myosteatosis, are common in non-dialysis chronic kidney disease (ND-CKD) patients and seem to be associated with adverse clinical outcomes. Sarcopenia and myosteatosis can be evaluated by computed tomography (CT) by measuring skeletal muscle area (SMA) and muscular attenuation (MA) in Hounsfield units (HU) at the third lumbar vertebra, respectively, but the optimal cutoff points for diagnosis and outcome prediction are not established in chronic kidney disease (CKD) patients. We aimed to evaluate the prevalence of sarcopenia and myosteatosis in ND-CKD patients and to define the optimal cutoff values of SMA and MA to predict mortality. Method We conducted a retrospective cohort study including non-dialysis CKD patients referred to an outpatient clinic during a two-year period, who underwent a CT as part of clinical workup and with an available serum creatinine evaluation within a 90-days timeframe. Patients with a follow-up under 26 weeks after the CT were excluded. Area under the receiver operating characteristic curve (AuROC) analysis was used to evaluate the ability of SMA and MA to predict mortality and the Youden's index was used to determine the optimal cutoff point. Cox-regression analysis was employed to identify independent predictors of mortality. Results 167 patients (94% Caucasian, 50.9% male, 32.3% diabetics) with a mean age of 68.3 ± 16.4 years were included, most with CKD stage 3 and 4 (53.9%; mean estimated GFR 57.6 ± 33,1 ml/min/1.73m2 at baseline). During a median follow-up of 4.9 (4.2) years, 39 patients (23.4%) died. Median SMA was 127.7 (45.8) cm2 and there was a trend to increased mortality across lower SMA quartiles (1st quartile 32.6%, p = 0.026; 2nd quartile 26.8%, p = 0.095; 3rd quartile 21.4%, p = 0.261; 4th quartile 21.2% - reference). SMA showed a modest ability to predict mortality (AuROC 0.623) and the best cutoff found was 140.7 cm2. Median MA was 28.4 (13.8) HU and there was a statistically significant higher mortality across lower MA quartiles (1st quartile 42.9%, p<0.001; 2nd quartile 31.0%, p = 0.001; 3rd quartile 16.7%, p = 0.028; 4th quartile 2.4% - reference). MA showed a good ability to predict mortality (AuROC 0.733) and the best cutoff was 30 HU. Using the identified cutoff points, sarcopenia (SMA < 140.7 cm2) was present in 67.1% (n = 112) and myosteatosis (MA < 30 HU) in 56.3% (n = 94) of patients. In univariate Cox-regression both sarcopenia and myosteatosis were associated with increased mortality – Hazard ratio (HR) 4.34 (95% CI 1.68-11.19, p = 0.002) and 5.32 (95% CI 2.22-12.73, p<0.001), respectively. In multivariate Cox-regression models (adjusted for age, baseline estimated GFR and presence of diabetes) only myosteatosis kept its association with mortality – HR 2.87 (95% CI 1.15-7.16, p = 0.024). This association was also present when the model was adjusted for the presence of sarcopenia. Patients with myosteatosis were older (median age 77.3 [10.8] vs 62.7 [30.1], p<0.001) and had higher frequency of diabetes (42.6% vs 19.2%, p = 0.001), arterial hypertension (87.2% vs 57.5%, p<0,001), and heart failure (24.5% vs 6.8%, p<0.003). They had also higher BMI (29.3 [7.4] vs 25.1 [6.0] kg/m2, p<0,001), visceral obesity (77.7% vs 43.8%, p<0.001) and frequency of sarcopenia (75.5% vs 56.2%, p = 0.008). Myosteatosis was more frequent in CKD stage 3 to 5 patients, compared to CKD stage 1 or 2 (66.3% vs 42%, p = 0.002). Conclusion Sarcopenia and myosteatosis are prevalent in CKD patients, especially in advanced stages. However, reference values for this population are lacking. We found cutoff values for these muscle parameters using CT analysis in CKD patients, based on optimal stratification for mortality. Additionally, our study highlights that muscle quality (i.e., myosteatosis) may be more closely associated with mortality than muscle quantity (i.e., sarcopenia). Identifying patients at risk for these muscle abnormalities and early diagnosis are paramount for the subsequent implementation of therapeutic interventions.

Abstract Background and Aims nutritional status clearly has a great impact on the prognosis of maintenance hemodialysis patients. Therefore, its management should be a priority and risk screening frequent and easily implemented, based on the biochemical and clinical routine parameters already available. Many tools fit these simple criteria, namely simple Protein Energy Wasting score (sPEW), Geriatric Nutritional Risk Index (GNRI) and Creatinine Index (Cr Index). These scores are associated with a high mortality and morbidity risk in hemodialysis (HD) patients. The objective of this study was to assess the performance of these tools regarding the estimation of all-cause mortality, in a 45-months follow-up of a large patient cohort. Method Historical cohort study of HD pts from 25 outpatient clinics. sPEW, GNRI and Cr Index were estimated. Kaplan-Meier estimator and univariable Cox regression models to analyze time until death were used. To compare survival curves the log-rank test or Tarone test were used, as appropriate. The level of significance α = .05 was considered. All data were analyzed using SPSS 22.0 (IBM Corp. Released 2013. IBM SPSS Statistics for Windows. Armonk, NY, USA: IBM Corp). Results We analyzed 2322 pts, 59% males, 31.7% diabetic, with a median age of 70 years (P25 = 60, P75 = 79) followed up for a maximum of 45-month (P25 = 31; P75 = 45). All-cause mortality was observed in 778 pts (33.5%). To assess the mortality risk, the exposures GNRI and CR Index, were discretized using quartiles. GNRI The median was 106.6 (P25 = 99.4, P75 = 114.2). The log-rank test results showed a significantly lower survival for patients in GNRI Q1 category (GNRI ≤ 99.4). A p-value <0.001 was obtained when comparing patients in Q4, Q3 and Q2 with patients in Q1. The univariable Cox regression model showed that patients in Q1 had a 2-fold increased risk of death, when compared with Q4 (HR = 2.1, 95% CI: 1.7-2.6, p<0.001). Creatinine Index The median was 12.648 (P25 = 11.908, P75 = 13.406). The log-rank test for the equality of survival functions for the different levels was considered statistically significant and showed a significantly lower survival for patients in CR Index Q1 category, when compared with the remaining categories (p<0.001). The univariable Cox regression model showed that comparatively with Q4, patients in Q1 had a 5-fold increased risk of death (HR = 4.8, 95% CI: 3.7-6.0, p<0.001), patients in Q2 a 3-fold increased risk of death (HR = 3.1, 95% CI:2.4– 3.9, p<0.001), and patients in Q3 a 2-fold increased risk of death (HR = 1.9, 95% CI: 1.4 – 2.4, p<0.001). sPEW The frequency of each score from 0 to 4 was 306, 380, 111, 1369 and 156, respectively. The log-rank test for the equality of survival functions corresponding to the different levels showed a significantly higher survival for patients with a sPEW score of 4 when comparing with the remaining levels (p<0.001). The univariable Cox regression model showed that comparatively with a score of 4, patients with a: score of 0 had an 8-fold increased risk of death (HR = 7.7, 95% CI: 4.5-13.3, p<0.001), score of 1 a 6-fold increase risk of death (HR = 5.6, 95% CI: 3.3– 9.7, p<0.001), score of 2 a 4-fold increase risk of death (HR = 4.1, 95% CI: 2.2– 7.7, p<0.001), and a score of 3, almost a 4-fold increased risk of death (HR = 3.7, 95% CI: 2.2– 6.3, p<0.001). Conclusion In this exploratory analysis, the three tools showed a significant association with mortality during follow-up. These tools, if adequately validated in future studies, may select patients for further intervention to modify the outcome.

Abstract BACKGROUND AND AIMS Autosomal dominant polycystic kidney disease (ADPKD) is a hereditary disease characterized by the formation and growth of renal cysts, affecting the decrease of renal function, which may lead to end-stage renal disease (ESRD). Due to the enormous intrafamilial phenotypic variability of ADPKD and since serum creatinine and glomerular filtration rate (GFR) have a limited ability to assess the disease and predict its progression at earlier stages, there is a need to find new biomarkers to predict disease progression. The α-glutathione s-transferase (GST-α) and haptoglobin (Hp) are produced mainly by the proximal convoluted tubule, and these enzymes are released into the urinary lumen in direct response to tubular damage. This study aims to evaluate the urine concentration of α-GST and Hp biomarkers at different stages of ADPKD progression and correlate the levels of urinary biomarkers α-GST and Hp with traditional markers of renal dysfunction. METHOD Twenty-five patients with ADPKD, mean age of 41.57 ± 14.43 years, mostly female (56.0%), diagnosed according to the Ravine criteria and with a follow-up of at least 60 months. Demographic, hemodynamic, urinary creatinine (UCr) and serum creatinine (SCr) data were collected in baseline (T0) and at the end of the follow-up period (T1). GFR was determined using the CKD-EPI formula, grouping patients into early stages (CKD1 and CKD2) and advanced stages (CKD3 to CKD5). Biomarkers were determined by the ELISA method and indexed to UCr in T1. In addition, α-GST was determinate in a control sample composed of 17 individuals without diagnosed kidney disease. Statistical analysis was performed by SPSS version 26 with a significant value of P < 0.05. RESULTS Comparing the means of SCr and GFR between T0 and T1 were observed a decrease of renal function during the follow-up period (P = 0.013 and P = .017, respectively). About 14.4% of patients were in an advanced stage of kidney disease in T1, compared with 4.8% in T0. ADPKD patients had increased values of α-GST in relation to the control group (P < 0.001), but no difference in the SCr was found. We also found a trend for higher levels of HP in advanced stages of CKD (P = 0.071). In ADPKD patients, direct correlations were observed between the variation of SCr during the follow-up with α-GST and Hp (r = 0.606, P = 0.048 and r = 0.738, P = 0.037, respectively). A trend to correlation was found between the levels of Hp and the Scr in T1 (r = P = 0.058). CONCLUSION The levels of α-GST and Hp are associated with renal damage and may be helpful in the early identification of the decline in renal function in ADPKD patients.

The studied polymorphisms seem to directly impact and/or modulate levels of some biomarkers associated with progression and stage of CKD in ADPKD patients.

Accelerated and premature cardiovascular calcification is a hallmark of chronic kidney disease (CKD) patients. Valvular calcification (VC) is a critical indicator of cardiovascular disease and all-cause mortality in this population, lacking validated biomarkers for early diagnosis. Gla-rich protein (GRP) is a cardiovascular calcification inhibitor recently associated with vascular calcification, pulse pressure, mineral metabolism markers and kidney function. Here, we examined the association between GRP serum levels and mitral and aortic valves calcification in a cohort of 80 diabetic patients with CKD stages 2–4. Mitral and aortic valves calcification were detected in 36.2% and 34.4% of the patients and associated with lower GRP levels, even after adjustments for age and gender. In this pilot study, univariate, multivariate and Poisson regression analysis, show that low levels of GRP and magnesium (Mg), and high levels of phosphate (P) are associated with mitral and aortic valves calcification. Receiver operating characteristic (ROC) curves showed that the area under the curve (AUC) values of GRP for mitral (0.762) and aortic (0.802) valves calcification were higher than those of Mg and P. These results suggest that low levels of GRP and Mg, and high levels of P, are independent and cumulative risk factors for VC in this population; the GRP diagnostic value might be potentially useful in cardiovascular risk assessment.

Autosomal Dominant Polycystic Kidney Disease (ADPKD) has several renal and extra-renal manifestations. Studies have reported a higher incidence of aortic aneurysms (AAs)/aortic dissections (ADs) in these patients, and we believe ADPKD should be considered as a risk factor for AA/AD. In order to support our opinion we conducted a systematic review and meta-analysis analyzing the risk of AA/AD in ADPKD patients. We searched MEDLINE, CENTRAL, PsycInfo, Web of Science Core Collection and OpenGrey for observational studies reporting frequency estimates of AA/AD in ADPKD patients compared with controls. We analyzed the odds ratio (OR) of the existence of an AA/AD in patients with ADPKD compared to controls. We also analyzed the odds of having an AA in patients with ADPKD compared to controls, the odds of having an AD in patients with ADPKD compared to controls, differences among subtypes of AA or AD, differences according to age, gender and different study designs. Seven observational studies were included. ADPKD was associated with a higher risk of AA or AD as compared with a population without the disease (OR 4.33; 95% CI 2.69; 6.97, p < 0.001); higher risk of AA (OR 4.18; 95% CI 2.36; 7.40, p < 0.001) and higher risk of AD (OR 9.08; 95% CI 3.11; 26.55, p < 0.001). Our point of view, suggesting the inclusion of aortic aneurysms and aortic dissection in the potential complications of ADPKD, was supported by our systematic review and meta-analysis showing that ADPKD was associated with a significant risk of having/developing an AA/AD. However, the risk of bias of included studies was considered high and these results should be interpreted cautiously. This association should be considered in clinical practice, although further studies are needed to consolidate these findings.

Enhanced recovery after surgery (ERAS) protocol is an evidence-based programme that englobe more restrictive fluid therapy to maintain euvolemia and the use of multimodal analgesia, which includes non-steroidal anti-inflammatory drugs (NSAIDs). Consequently, it's pertinent to assess the risk and potential consequences of acute kidney injury (AKI) in the short and medium term. A descriptive and single-center retrospective study, which included 428 patients that were submitted to colon-rectal surgery according to ERAS protocol between November 2016 and May 2020. AKI was defined according to KDIGO criteria. Data were collected from 428 patients. AKI occurred in 25.2% of patients (108), mostly KDIGO 1 (63.9%) and 6.5% required haemodialysis. The median time of follow-up was 25.6 months (IQ 15.6–38.8). Patient-related variables that positively influenced AKI were ASA Class III/IV [F (1, 426) = 23.2; P < .001], diabetes [F (1, 426) = 9.96; P = .002], severe heart disease [F (1, 426) = 7.12; P = .008], CKD [F (1, 425) = 11.58; P < .001], obesity [F (1, 423) = 14.21; P < .001] and use of ACE inhibitors/ARBs [F (1, 425) = 17.4; P < .001]. Preoperative and surgery-related variables that influenced AKI were preoperative haemoglobin [F (85, 338) = 1.36; P = .030], open approach [F (1, 424) = 21.5; P < .001], NSAIDs [F (1–426) = 5.77; P = .017], iodinated intravenous contrast exposure [F (1, 424) = 26.8; P < .001), postoperative support aminergic [F (1, 424) = 18.9; P < .001], surgery complications [F (1, 426) = 36.5; P < .001] and blood transfusion [F (1, 426) = 10.15; P = 0.002]. AKI group had a superior length of stay (9 versus 6 days; P < .001), ICU admission (31.5% versus 8.8%; P <.001), readmission at 30 days (12% versus 5.6%; P = .027) and mortality (23.1% versus 6.6%; P < .001). Kaplan–Meier analysis showed that the AKI group was associated with lower survival (log-rank test = 26.601; P < .001). We also found that the AKI group was associated with a greater reduction in GFR after 2 years (3.3 mL/min/1.73 m2 versus 1.8 mL/min/1.73 m2; P = .009). AKI was frequent among ERAS patients and was associated with worst outcomes—higher costs (since it was associated to longer hospitalization, higher readmission at 30 days and ICU admission), higher risk of reduction in GFR in the first 2 years and higher mortality.

Portugal has one of the highest rates of prevalence and incidence of dialysis in Europe.Several reasons have been hypothesized to explain this scenario, ranging from demography, social and economic factors, and ethical issues 1 .Data supporting this picture came from the Annual Report of the Portuguese Society of Nephrology (PSN), covering almost 100% of information of patients starting and under renal replacement therapy (RRT) since 1997.The report's comprehensive nature and consistency and regularity is one of its major strength and a great achievement of our society.

Abstract Background and Aims Anemia is a well-know complication of Chronic Kidney Disease (CKD) and it seems to contribute for deterioration of kidney function. Experimental data suggest that anemia produces hypoxia of tubular cells which leads to tubulointerstitial damage resulting on CKD progression. Other mechanism described is that red blood cells have antioxidant properties that prevent the damage of tubulointerstitial cells and glomerulosclerosis from oxidative stress. There aren’t many observational studies that evaluated the association between anemia and progression of CKD. Therefore, our aim was to evaluate the association of anemia and CKD progression and its association outcomes in an outpatient ND-CKD population. Method We conduct a retrospective, patient-level, cohort analysis of all adult ND-CKD patients evaluated in an outpatient nephrology clinic over a 6 years period. The follow up time was at least 12 months. Anemia was defined according to the WHO definition (hemoglobin [hb] < 13.0 g/dL in men and 12.0 g/dL in women). Progression of CKD was defined by one of the following criteria: decline in eGFR (CKD-EPI) superior to 5 ml/min/1.73 m2/year; duplication of serum creatinine or the need renal replacement therapy. Demographics and clinical data were also accessed. Results Out of 3008 patients referred to the nephrology clinic, 49.9% had anemia (mean age 71.9±15.9 years; 50.4% male; 92% white; mean follow-up time of 2.3±1.2 years). The mean Hb was 11.8 ±1.9 g/dL. Important cardiovascular comorbidities in patients with anemia were arterial hypertension (86.7%), obesity (65.5%), Diabetes Mellitus (DM) (52%) and dyslipidemia (46%). In univariate analysis, mortality was associated with anemia (36.9 vs 13.0%, p<0.001), obesity (30.1 vs 21.8%, p<0.001) and DM (30.1 vs 21.1%, p<0.001). Of the patients with anemia, 738 met the criteria for CKD progression. In univariate analysis, CKD progression was associated with anemia (49.6 vs 43.9%, p=0.002), male gender (49.5 vs 43.6% p= 0.001); DM (49.6 vs 44.8 % p=0.009) and hypertension (47.9 vs 42.3% p=0.0018). In multivariate logistic regression analysis, anemia emerged was an independent predictor of CKD progression (OR 1.435, CI 95% 1.21-1.71, p<0,001). Comparing hb values intervals (hb ≤10g/dl; hb10-12 g/dL; hb ≥12 g/dL), in the multivariate logistic regression analysis, hb ≤10g/dl was not associated with CKD progression and hb value between 10-12 g/dL was associated (OR 1,486, CI 95% 1.23-1.80, p<0,001), when compared with the group with hb ≥12g/dL. In multivariate logistic regression analysis, the independent predictors of mortality were: older age (OR per 1 year increase: 1.048, 95% CI 95% 1.04-1.06, p<0.001); arterial hypertension (OR 0.699 CI 95% 0.51-0.96, p=0.0029); obesity (OR 0.741, CI 95% 0.60-0.91, p=0.004) and hb value (OR per 1 g/dL decrease: 1.301, CI 95% 1.23-1.38, p<0.001). Cardiovascular events were correlated with Hb levels between 10-12 g/dL (univariate analysis: OR 2.021, CI 95% 1.27-3.22, P=0.003), but not with the group with hb≤10 g/dL (univariate analysis: OR 1.837, CI 95% 0.96-3.51, P=0.066), having the group with hb ≥12g/dL was reference. Anemia was strongly associated with hospitalizations (multivariate logistic regression analysis: OR per 1 g/dL of Hb decrease: 1.256 CI 95% 1.12-1.32 p<0.001), and this strong association was also observed on the groups with hb hb≤10 g/dL (multivariate logistic regression analysis: OR 3.591 CI 95% 32.67-4.84 p<0.001) and between 10-12 g/dL (multivariate logistic regression analysis: OR 1.678 CI 95% 1.40-2.02, p<0.001) Conclusion Our study suggests that anemia, at first consultation, increases the risk for rapid CKD progression and global mortality. This study could guide us on the development of futures studies in order to prove if anemia correction can slow the progression of CKD.