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Management of complications associated with chronic kidney disease in kidney transplant recipients vs stage 5 native CKD patients
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Introdução: A doença renal crónica (DRC) representa um encargo substancial para os sistemas de saúde a nível mundial, prevendo-se um aumento da sua prevalência e dos custos associados. A terapia de substituição renal (TSR), em particular o transplante renal, é uma pedra angular na gestão da DRC, mas persistem desafios, especialmente em doentes com falência do enxerto e em transição para a diálise, que podem estar a receber um tratamento pior e cujas complicações podem não estar a ser devidamente geridas. Através de uma análise retrospetiva, procurámos esclarecer as disparidades entre os doentes com DRC nativa e os doentes transplantados que iniciam diálise, salientando a complexidade da gestão da DRC em diversas populações de doentes.
Métodos: Comparámos doentes com DRC nativa (NKD) e doentes com perda de enxerto (Tx) que iniciaram diálise no Centro Hospitalar Universitário Lisboa Norte (CHULN) entre 2021 e 2023 numa proporção de 3:1. Em termos de variáveis foram consideradas: Idade de início da hemodiálise (HD), sexo, transplante ou insuficiência renal nativa, causa da DRC, comorbidades (Diabetes Melitus (DM) ou Hipertensão Arterial (HBP)), laboratório no início da HD (T0) e três meses anteriores( T3); tipo de acesso vascular no início da HD e início planeado da TSR. Foram considerados como resultados: o tipo de início da HD [eletiva (vs. início durante internamento/urgência) e utilização de cateter como acesso vascular] bem como a situação dos pacientes quanto aos níveis terapêuticos de hemoglobina (acima de 10g/dL) e bicarbonato (acima de 22 mmol/ EU). Resultados: O estudo incluiu 112 participantes, dos quais 78 (69,6%) foram classificados como NKD e 34 (30,4%) como Tx. A idade dos participantes variou de 25 a 90 anos, com uma média de 65,8 anos. 66 (58,9%) eram do sexo masculino e 46 (41,1%) do sexo feminino. Os doentes NKD demonstraram uma maior prevalência de início planeado de TSR (88,5% vs. 47,1%, p < 0,001) e de início eletivo de TSR (91,0% vs. 32,4%, p < 0,001). Eram notoriamente mais jovens no início da TSR do que os pacientes Tx (52,1 anos vs. 70,2 anos, p < 0,001). No início da hemodiálise (HD), foram observadas diferenças significativas nos níveis de bicarbonato (21,39 mmol/L em NKD vs. 19,26 mmol/L em Tx, p = 0,011) e na proporção de doentes que atingiram níveis de hemoglobina de 10 g/dL (65,4% em NKD vs. 41,2% em Tx, p = 0,017). Em T3, observaram-se tendências consistentes, com diferenças nos níveis de HCO3- (21,87 mmol/L em NKD vs. 19,18 mmol/L no grupo Tx, p = 0,001) e na proporção de doentes que atingiram os objectivos de hemoglobina (78,2% em NKD vs. 58,8% em Tx, p = 0,035). Para além disso, foi observada uma disparidade significativa nos níveis de PTH entre os grupos em T3 (381,55 pg/mL em NKD vs. 541,73 pg/mL em Tx, p = 0,014).
Conclusões: Esta análise retrospetiva pode revelar diferenças na gestão da DRC entre doentes transplantados e doentes renais nativos, nomeadamente no início da diálise. Os recetores de transplante parecem apresentar um início de diálise menos programado, necessitando frequentemente de intervenções de emergência, enquanto os doentes com DRC nativa demonstram um melhor controlo da anemia e da acidose metabólica. Estes resultados sublinham o impacto do status do transplante nas trajetórias de gestão da DRC e realçam a possibilidade de diferenças na prestação de cuidados tendo em conta doentes com diferentes características, sendo necessária mais investigação para compreender estas diferenças de forma abrangente e desenvolver intervenções adaptadas a diversas populações de doentes.
Introduction: Chronic kidney disease (CKD) presents a substantial global health burden, projected to escalate in prevalence and associated costs. Renal replacement therapy (RRT), particularly kidney transplantation, stands as a cornerstone in CKD management, yet challenges persist, especially in patients experiencing graft failure and transitioning to dialysis, who may be receiving worse treatment and whose complications may not be properly managed. Through a retrospective analysis, we sought to illuminate the disparities between native CKD and transplant patients initiating dialysis, highlighting the complexity of CKD management across diverse patient populations. Methods: We compared patients with native CKD (NKD) and those with graft loss (Tx) initiating dialysis at Centro Hospitalar Universitário Lisboa Norte (CHULN) between 2021 and 2023 at a ratio of 3:1. In terms of variables we considered: Age at hemodialysis (HD) start, sex, transplant or native kidney failure, cause of CKD, comorbidities (Diabetes Mellitus (DM) or Hypertension (HBP)), laboratory at HD start (T0) and three months prior (T3); type of vascular access at HD start, and planned start of renal replacement therapy (RRT). We considered as outcomes: type of start of HD [outpatient / elective (vs start during hospitalisation / urgent) and Catheter as vascular access] as well as the patients’ status regarding therapeutic levels of haemoglobin (over 10g/dL) and Bicarbonate (over 22 mmol/dL) Results: The study comprised 112 participants, with 78 (69.6%) categorized as NKD and 34 (30.4%) as Tx recipients. Participants ranged in age from 25 to 90 years, with an average age of 65.8 years. Among them, 66 (58.9%) were male and 46 (41.1%) were female. NKD patients demonstrated a higher prevalence of planned RRT initiation (88.5% vs. 47.1%, p < 0.001) and elective RRT start (91.0% vs. 32.4%, p < 0.001). They were notably younger at RRT initiation than Tx patients (52.1 years vs. 70.2 years, p < 0.001). At RRT start, significant differences were observed in bicarbonate levels (21.39 mmol/L in NKD vs. 19.26 mmol/L in Tx, p = 0.011) and the proportion of patients achieving haemoglobin levels over 10 g/dL (65.4% in NKD vs. 41.2% in Tx, p = 0.017). At T3, consistent trends were observed, with differences in HCO3- levels (21.87 mmol/L in NKD vs. 19.18 mmol/L in Tx, p = 0.001) and the proportion of patients meeting haemoglobin targets (78.2% in NKD vs. 58.8% in Tx, p = 0.035). Furthermore, a significant disparity in PTH levels between groups was noted at T3 (381.55 pg/mL in NKD vs. 541.73 pg/mL in Tx, p = 0.014). Conclusion: This retrospective analysis may reveal disparities in CKD management between transplant and native kidney disease patients, notably at the initiation of dialysis. Transplant recipients seem to exhibit a less programmed start, often requiring emergent interventions, while native CKD patients demonstrate better anaemia and metabolic acidosis control. These findings emphasize the impact of transplantation status on CKD management trajectories and highlight the need for further research to understand these differences comprehensively and develop tailored interventions for diverse patient populations.
Introduction: Chronic kidney disease (CKD) presents a substantial global health burden, projected to escalate in prevalence and associated costs. Renal replacement therapy (RRT), particularly kidney transplantation, stands as a cornerstone in CKD management, yet challenges persist, especially in patients experiencing graft failure and transitioning to dialysis, who may be receiving worse treatment and whose complications may not be properly managed. Through a retrospective analysis, we sought to illuminate the disparities between native CKD and transplant patients initiating dialysis, highlighting the complexity of CKD management across diverse patient populations. Methods: We compared patients with native CKD (NKD) and those with graft loss (Tx) initiating dialysis at Centro Hospitalar Universitário Lisboa Norte (CHULN) between 2021 and 2023 at a ratio of 3:1. In terms of variables we considered: Age at hemodialysis (HD) start, sex, transplant or native kidney failure, cause of CKD, comorbidities (Diabetes Mellitus (DM) or Hypertension (HBP)), laboratory at HD start (T0) and three months prior (T3); type of vascular access at HD start, and planned start of renal replacement therapy (RRT). We considered as outcomes: type of start of HD [outpatient / elective (vs start during hospitalisation / urgent) and Catheter as vascular access] as well as the patients’ status regarding therapeutic levels of haemoglobin (over 10g/dL) and Bicarbonate (over 22 mmol/dL) Results: The study comprised 112 participants, with 78 (69.6%) categorized as NKD and 34 (30.4%) as Tx recipients. Participants ranged in age from 25 to 90 years, with an average age of 65.8 years. Among them, 66 (58.9%) were male and 46 (41.1%) were female. NKD patients demonstrated a higher prevalence of planned RRT initiation (88.5% vs. 47.1%, p < 0.001) and elective RRT start (91.0% vs. 32.4%, p < 0.001). They were notably younger at RRT initiation than Tx patients (52.1 years vs. 70.2 years, p < 0.001). At RRT start, significant differences were observed in bicarbonate levels (21.39 mmol/L in NKD vs. 19.26 mmol/L in Tx, p = 0.011) and the proportion of patients achieving haemoglobin levels over 10 g/dL (65.4% in NKD vs. 41.2% in Tx, p = 0.017). At T3, consistent trends were observed, with differences in HCO3- levels (21.87 mmol/L in NKD vs. 19.18 mmol/L in Tx, p = 0.001) and the proportion of patients meeting haemoglobin targets (78.2% in NKD vs. 58.8% in Tx, p = 0.035). Furthermore, a significant disparity in PTH levels between groups was noted at T3 (381.55 pg/mL in NKD vs. 541.73 pg/mL in Tx, p = 0.014). Conclusion: This retrospective analysis may reveal disparities in CKD management between transplant and native kidney disease patients, notably at the initiation of dialysis. Transplant recipients seem to exhibit a less programmed start, often requiring emergent interventions, while native CKD patients demonstrate better anaemia and metabolic acidosis control. These findings emphasize the impact of transplantation status on CKD management trajectories and highlight the need for further research to understand these differences comprehensively and develop tailored interventions for diverse patient populations.
Descrição
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2024
Palavras-chave
Chronic kidney disease (CKD) Dialysis after graft loss (DAGL) Recipient with failing kidney transplant (RFKT) Nefrologia