Browsing by Author "Branco, P"
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- A 2018 Overview of Diuretic Resistance in Heart FailurePublication . Jardim, SI; Ramos dos Santos, L; Araújo, I; Marques, F; Branco, P; Gaspar, A; Fonseca, CHeart failure is a disease with high direct and indirect costs. Current treatment includes drugs that alter disease progression and drugs that to improve symptoms. Loop diuretics are the cornerstone of congestion relief for acute management, as well as for chronic stabilization. In heart failure patients, maximal diuretic response is reduced by many individual factors. Diuretic resistance is defined as failure to achieve effective congestion relief despite appropriate or escalating diuretic doses. Its causes include impaired delivery of the diuretic to its luminal site of action, neurohormonal activation, tubular compensatory adaptation and drug interactions. Several strategies can be employed to aid decongestion of patients with impaired diuretic response. These include salt restriction, a higher effective single dose or higher dose frequency of loop diuretics, continuous infusion of diuretics and/or sequential nephron blockade through a synergistic combination of two or more diuretics from different classes. Ultrafiltration has also been found to be another effective and safe therapeutic option and should be considered in patients with refractory diuretic resistance. Overall, there is a lack of high-quality clinical data to guide the choice of treatment strategy and therapy should be tailored on a case-by-case basis.
- Anemia and Iron Deficiency Diagnosis, Management and Treatment in Chronic Kidney Disease - Consensus and Agreement through a Delphi PanelPublication . Ferreira, A; Farinha, A; Macedo, A; Robalo Nunes, A; Lopes, J; Branco, P; Ponce, P; Neto, RBackground: Anemia is a common complication of Chronic Kidney Disease (CKD), in which iron deficiency’s (ID) role is frequently underrated. In CKD, anemia has been associated with higher morbidity and lower quality of life. Nonetheless, reported treatment rates of anemia in CKD are low and guidelines’ variability and/or absence for its management and treatment may be preventing patients from receiving optimal treatment. Within this context, we aimed to assess the agreement level on anemia and iron deficiency diagnosis, management, and treatment in CKD patients, by Portuguese physicians in Nephrology, through a Delphi Panel. Methods: A group of seven medical experts in Nephrology and Transfusion Medicine was assembled, and a focus group was conducted, in which 28 statements were agreed upon. Then, a two-round Delphi Panel using a Likert scale was conducted online, inviting Portuguese Society of Nephrology associates to participate. Results: Answers were collected from 76 participants in Round 1 and consensus level was obtained for 1 statement, 57 (75%) respondents fully disagreeing on transfusing all patients with hemoglobin below 9 g/dl, regardless of the clinical situation. The remaining 27 statements were used in Round 2, none obtaining consensus level and 14 statements being categorized as qualified majority: 4 on diagnosis, 3 on disease management, and 7 on treatment. Discussion: Our study showed a lack of consensus on diagnosis, management, and treatment of anemia in CKD patients among the nephrology community in Portugal. Overall, our results illustrated the heterogeneity of national clinical practices in: laboratory parameters’ choice; cutoff values defining anemia and/or ID; parameter-based therapeutic decisions. Nonetheless, it was shown clear that patient’s individual characteristics, clinical settings, and the physician’s “clinical sense” seem to be considered to a further extent than the available guidelines. Future studies should be considered to develop recommendations that can be widely accepted.
- A Comparative Study of Cardiovascular Tolerability with Slow Extended Dialysis Versus Continuous Haemodiafiltration in the Critical PatientPublication . Birne, R; Branco, P; Marcelino, P; Marum, S; Fernandes, AP; Viana, H; Adragão, T; Ferreira, A; Mourão, LBackground: In the haemodynamically unstable patient the method of treatment of acute renal failure is still largely controversial. The purpose of our study was to compare slow extended dialysis with continuous haemodiafiltration in the critical patient with indication for renal replacement therapy and haemodynamic instability. Patients and Methods: This is a cohort study comparing in 63 ventilated critical patients a 12 month period when only continuous haemodiafiltration was used (n=25) with an equal period of slow extended dialysis (n=38). Our primary objective was to evaluate the impact of the dialytic procedure on cardiovascular stability in those patients. As secondary aims we considered system coagulation/thrombosis and predictors of mortality. In the two groups we analysed the first session performed, the second session performed and the average of all the sessions performed in each patient. Results: In these patients, mortality in the intensive care unit was high (68% in the continuous haemodiafiltration group and 63% in the slow extended dialysis group). We did not find any association between the dialytic technique used and death; only the APACHE score was a predictor of death. Slow extended dialysis was a predictor of haemodynamic stability, a negative predictor of sessions that had to be interrupted for haemodynamic instability, and a predictor of achieving the volume removal initially sought. Slow extended dialysis was also associated with less coagulation of the system. Conclusions: Our data suggested that slow extended dialysis use was not inferior to continuous haemodiafiltration use in terms of cardiovascular tolerability.
- Effect of Empagliflozin Beyond Glycemic Control: Cardiovascular Benefit in Patients with Type 2 Diabetes and Established Cardiovascular DiseasePublication . Monteiro, P; Aguiar, C; Matos, P; Silva-Nunes, J; Birne, R; Branco, P; Calado, J; Melo, M; Polónia, JThe prevalence of type 2 diabetes (T2D) continues to increase, and its association with cardiovascular (CV) disease has led to the inclusion of CV endpoints in clinical trials on the treatment of T2D. This article explores the various trials already performed and under development in this field, with particular focus on the EMPA-REG OUTCOME trial. In this trial, empagliflozin, a sodium-glucose co-transporter 2 inhibitor, demonstrated a reduction in CV risk in patients with T2D and established CV disease, in addition to CV safety and a decrease in glycated hemoglobin. This represents a paradigm shift that has led to changes in the international guidelines for the treatment of T2D. These results were maintained in subsequent subgroup analysis for heart failure, chronic kidney disease and peripheral arterial disease, although there are many questions concerning the mechanisms involved in these effects, including whether they are hemodynamic, metabolic or due to decreased myocardial cytoplasmic sodium concentrations. With this reduction in risk for major CV events in patients with T2D, the EMPA-REG OUTCOME trial demonstrated CV protection from a hypoglycemic drug for the first time, and opened a new era in the treatment and management of T2D. This study has led to the development of ongoing trials that will establish which patients will benefit most from this therapy, particularly with regard to comorbidities.
- Empagliflozina e a Nova Era no Tratamento da Diabetes Tipo 2: Para Além do Controlo GlicémicoPublication . Silva Nunes, J; Aguiar, C; Birne, R; Branco, P; Calado, J; Matos, P; Melo, M; Monteiro, P; Polónia, JA diabetes mellitus tipo 2 (DMT2) tem associado um risco aumentado de mortalidade, principalmente, por doença cardiovascular (DCV). Interessa ter disponíveis opções terapêuticas que permitam o controlo glicémico mas que considerem, igualmente, a atuação sobre fatores de risco cardiovascular e a redução de eventos micro e macrovasculares. Nos últimos anos foram desenvolvidos vários inibidores do transporte renal de glicose via cotransporte de sódio/glicose (iSGLT), nomeadamente a empagliflozina, para promover a excreção urinária de glicose filtrada pelo rim. A empagliflozina é um inibidor competitivo, reversível, altamente potente e seletivo dos SGLT2, indicada no tratamento da hiperglicemia da DMT2. O EMPA-REG OUTCOME®, um ensaio clínico de resultados cardiovasculares aleatorizado, em dupla ocultação, controlado com placebo, que incluiu 7020 indivíduos com DMT2 e DCV estabelecida, avaliou o efeito da empagliflozina versus placebo, associado ao tratamento standard, na ocorrência de um compósito de 3 pontos MACE (Major Adverse Cardiovascular Events) - morte por causa cardiovascular, acidente vascular cerebral não fatal ou enfarte agudo de miocárdio não fatal. Com os resultados do EMPA-REG OUTCOME®, a empagliflozina foi o primeiro iSGLT2 a demonstrar uma redução de morbilidade cardiovascular em indivíduos com DMT2 com elevado risco cardiovascular, adicionando a proteção cardiovascular ao efeito anti-hiperglicémico do fármaco e abrindo uma nova era no tratamento e gestão da DMT2.
- Gravidez e DiálisePublication . Pires, A; Branco, P; Adragão, A; Borges, AA gravidez nas mulheres insuficientes renais crónicas tratadas com diálise é pouco frequente, mas tem aumentado nos últimos anos e o seu prognóstico tem melhorado. Uma gravidez bem-sucedida é mais frequente nas mulheres com função residual, sobretudo se a concepção ocorre antes de iniciar diálise ou se estão em diálise há menos de 1 ano. No entanto, numa doente com insuficiência renal moderada a grave, há risco de deterioração acelerada da função renal. Os resultados são semelhantes com ambas as modalidades de substituição da função renal, hemodiálise ou diálise peritoneal. A prescrição dialítica deve visar uma ureia inferior a 100mg/dl. As complicações maternas, que incluem hipertensão, anemia, perturbações do metabolismo fósfo-cálcico e deficits nutricionais, devem ser prevenidas e/ou tratadas atempadamente. A prematuridade e as perdas fetais são frequentes. A sobrevivência do recém-nascido e o bem-estar da mãe impõem a cooperação estreita entre médicos, enfermeiros e nutricionistas das áreas da obstetrícia, nefrologia e neonatologia.
- Gravidez na Transplantação RenalPublication . Branco, P; Pires, A; Adragão, T; Borges, ACom a Transplantação Renal regista-se recuperação da fertilidade. A exposição a fármacos imunossupressores, como a prednisona, a ciclosporina, a azatioprina e o tacrolimus não está associada com um aumento da incidência de malformações congénitas. A Imunossupressão, particularmente com a ciclosporina, está relacionada com recém-nascidos com baixo peso ao nascer. Doentes transplantados têm um risco aumentado de complicações infecciosas, algumas com implicações importantes para o feto, como as infecções por citomegalovírus, herpes simples e toxoplasmose. Esta população tem uma maior frequência de prematuridade, variando a percentagem de nados vivos entre 70 e 100%. Impõe-se a manutenção de esforços continuados para identificar os factores de risco pré-gestacionais, optimizando as estratégias de abordagem neonatal para uma gravidez bem-sucedida.
- Mineral and Bone Disease (MBD) on a Kidney Transplant PatientPublication . Birne, R; Adragão, T; Ferreira, A; Dickson, J; Silva, R; Casqueiro, A; Oliveira, R; Martins, AR; Torres, J; Matias, P; Branco, P; Jorge, C; Weigert, A; Bruges, M; Machado, DA 50-year-old post-menopausal recipient of a kidney allograft with bone pain, osteoporosis, persistent hypercalcaemia and elevated parathormone (PTH) levels, despite a satisfactory graft function, was treated with bisphosphonates and cinacalcet starting, respectively, 5 and 6 months after renal transplantation (RT). Sixteen months after treatment, there was improvement of bone mineral density (BMD) measured by dualenergy X-ray absorptiometry (DEXA). A bone biopsy was taken, unveiling a surprising and worrisome result. Post-RT bone disease is different from classic CKD-MBD and should be managed distinctly, including, in some difficult cases, an invasive evaluation through the performance of a bone biopsy, as suggested in the KDIGO guidelines.