Publications by authors named "José António Lopes"

59 Publications

Impact of Chronic RAAS Use in Elderly COVID-19 Patients: A Retrospective Analysis.

J Clin Med 2021 Jul 16;10(14). Epub 2021 Jul 16.

Department of Nephrology and Renal Transplantation, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal.

Corona Virus Disease-19 (COVID-19) recently emerged as a global pandemic. Advanced age is the most important risk factor for increased virus susceptibility and worse outcomes. Many older adults are currently treated with renin-angiotensin-aldosterone system (RAAS) inhibitors and there is concern that these medications might increase the risk of mortality by COVID-19. This is a retrospective cohort of 346 patients older than 65 years with COVID-19, at the Department of Medicine of the Centro Hospitalar Universitário Lisboa Norte, in Portugal, hospitalized between March 2020 and August 2020. Mean age was 80.9 ± 8.7 years old. Most patients had arterial hypertension (n = 279, 80.6%), almost half (n = 161, 46.5%) had cardiovascular disease and approximately one-third of patients had heart failure (n = 127, 36.7%) or diabetes Mellitus (n = 113, 32.7%). Ninety-eight patients (28.3%) had chronic kidney disease and almost half of the patients (49.4%) were chronically under renin-angiotensin-aldosterone system (RAAS) inhibitors. Twenty percent of patients died during hospitalization. In a multivariate analysis, older age (OR 1.11, 95% CI 1.04, 1.18, = 0.002), absence of baseline medication with RAAS inhibitors (OR 0.27, 95% CI 0.10, 0.75, = 0.011), higher serum ferritin (OR 1.00, 95% CI 1.00, 1.00, = 0.003) and higher lactate levels (OR 1.08, 95% CI 1.02, 1.14, = 0.006) were independent predictors of mortality. Older age, higher serum ferritin and lactate levels at admission were found to be independent predictors of mortality and might act as early predictors of worsening disease in clinical practice. Chronic treatment with RAAS inhibitors appeared to be protective, supporting guidelines in not discontinuing such drugs.
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http://dx.doi.org/10.3390/jcm10143147DOI Listing
July 2021

Acute kidney injury in hospitalized patients with COVID-19: A Portuguese cohort.

Nefrologia 2021 May 14. Epub 2021 May 14.

Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal.

Introduction: The incidence of acute kidney injury (AKI) in coronavirus disease 2019 (COVID-19) patients ranges from 0.5% to 35% and has been associated with worse prognosis. The purpose of this study was to evaluate the incidence, severity, duration, risk factors and prognosis of AKI in hospitalized patients with COVID-19.

Methods: We conducted a retrospective single-center analysis of 192 hospitalized COVID-19 patients from March to May of 2020. AKI was diagnosed using the Kidney Disease Improving Global Outcome (KDIGO) classification based on serum creatinine (SCr) criteria. Persistent and transient AKI were defined according to the Acute Disease Quality Initiative (ADQI) workgroup definitions.

Results: In this cohort of COVID-19 patients, 55.2% developed AKI (n=106). The majority of AKI patients had persistent AKI (n=64, 60.4%). Overall, in-hospital mortality was 18.2% (n=35) and was higher in AKI patients (28.3% vs. 5.9%, p<0.001, unadjusted OR 6.03 (2.22-16.37), p<0.001). In this multivariate analysis, older age (adjusted OR 1.07 (95% CI 1.02-1.11), p=0.004), lower Hb level (adjusted OR 0.78 (95% CI 0.60-0.98), p=0.035), duration of AKI (adjusted OR 7.34 for persistent AKI (95% CI 2.37-22.72), p=0.001) and severity of AKI (adjusted OR 2.65 per increase in KDIGO stage (95% CI 1.32-5.33), p=0.006) were independent predictors of mortality.

Conclusion: AKI was frequent in hospitalized patients with COVID-19. Persistent AKI and higher severity of AKI were independent predictors of in-hospital mortality.
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http://dx.doi.org/10.1016/j.nefro.2021.04.002DOI Listing
May 2021

Acute kidney injury in hospitalized patients with COVID-19: a Portuguese cohort.

Nefrologia (Engl Ed) 2021 May 14. Epub 2021 May 14.

Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal.

Introduction: The incidence of AKI in coronavirus disease 2019 (COVID-19) patients ranges from 0.5 to 35% and has been associated with worse prognosis. The purpose of this study was to evaluate the incidence, severity, duration, risk factors and prognosis of AKI in hospitalized patients with COVID-19.

Methods: We conducted a retrospective single-center analysis of 192 hospitalized COVID-19 patients from March to May of 2020. AKI was diagnosed using the Kidney Disease Improving Global Outcome (KDIGO) classification based on serum creatinine (SCr) criteria. Persistent and Transient AKI were defined according to the Acute Disease Quality Initiative (ADQI) workgroup definitions.

Results: In this cohort of COVID-19 patients, 55.2% developed AKI (n=106). The majority of AKI patients had persistent AKI (n=64, 60.4%). Overall, in-hospital mortality was 18.2% (n=35) and was higher in AKI patients (28.3% vs 5.9%, p<0.001, unadjusted OR 6.03 (2.22-16.37), p<0.001). In this multivariate analysis, older age (adjusted OR 1.07 (95% CI 1.02-1.11), p=0.004), lower Hb level (adjusted OR 0.78 (95% CI 0.60-0.98), p=0.035), duration of AKI (adjusted OR 7.34 for persistent AKI (95% CI 2.37-22.72), p=0.001) and severity of AKI (adjusted OR 2.65 per increase in KDIGO stage (95% CI 1.32-5.33), p=0.006) were independent predictors of mortality.

Conclusion: AKI was frequent in hospitalized patients with COVID-19. Persistent AKI and higher severity of AKI were independent predictors of in-hospital mortality.
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http://dx.doi.org/10.1016/j.nefro.2021.04.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8120482PMC
May 2021

Acute kidney disease and long-term outcomes in critically ill acute kidney injury patients with sepsis: a cohort analysis.

Clin Kidney J 2021 May 27;14(5):1379-1387. Epub 2020 Sep 27.

Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Lisboa, Portugal.

Background: Acute kidney injury (AKI) is frequent during hospitalization and may contribute to adverse short- and long-term consequences. Acute kidney disease (AKD) reflects the continuing pathological processes and adverse events developing after AKI. We aimed to evaluate the association of AKD, long-term adverse renal function and mortality in a cohort of patients with sepsis.

Methods: We performed a retrospective analysis of adult patients with septic AKI admitted to the Division of Intensive Medicine of the Centro Hospitalar Lisboa Norte (Lisbon, Portugal) between January 2008 and December 2014. Patients were categorized according to the development of AKI using the Kidney Disease: Improving Global Outcomes (KDIGO) classification. AKI was defined as an increase in absolute serum creatinine (SCr) ≥0.3 mg/dL or by a percentage increase in SCr ≥50% and/or by a decrease in urine output to <0.5 mL/kg/h for >6 h. AKD was defined as presenting at least KDIGO Stage 1 criteria for >7 days after an AKI initiating event. Adverse renal outcomes (need for long-term dialysis and/or a 25% decrease in estimated glomerular filtration rate after hospital discharge) and mortality after discharge were evaluated.

Results: From 256 selected patients with septic AKI, 53.9% developed AKD. The 30-day mortality rate was 24.5% ( = 55). The mean long-term follow-up was 45.9 ± 43.3 months. The majority of patients experience an adverse renal outcome [ = 158 (61.7%)] and 44.1% ( = 113) of patients died during follow-up. Adverse renal outcomes, 30-day mortality and long-term mortality after hospital discharge were more frequent among AKD patients [77.5 versus 43.2% (P < 0.001), 34.1 versus 6.8% (P < 0.001) and 64.8 versus 49.1% (P = 0.025), respectively]. The 5-year cumulative probability of survival was 23.2% for AKD patients, while it was 47.5% for patients with no AKD (log-rank test, P < 0.0001). In multivariate analysis, AKD was independently associated with adverse renal outcomes {adjusted hazard ratio [HR] 2.87 [95% confidence interval (CI) 2.0-4.1]; P < 0.001} and long-term mortality [adjusted HR 1.51 (95% CI 1.0-2.2); P = 0.040].

Conclusions: AKD after septic AKI was independently associated with the risk of long-term need for dialysis and/or renal function decline and with the risk of death after hospital discharge.
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http://dx.doi.org/10.1093/ckj/sfaa130DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8087131PMC
May 2021

Long-term consequences of acute kidney injury: a narrative review.

Clin Kidney J 2021 Mar 19;14(3):789-804. Epub 2020 Nov 19.

Department of Medicine, Division of Nephrology and Renal Transplantation, Centro Hospitalar Lisboa Norte, EPE, Lisboa, Portugal.

The incidence of acute kidney injury (AKI) has increased in the past decades. AKI complicates up to 15% of hospitalizations and can reach up to 50-60% in critically ill patients. Besides the short-term impact of AKI in patient outcomes, several studies report the association between AKI and adverse long-term outcomes, such as recurrent AKI episodes in 25-30% of cases, hospital re-admissions in up to 40% of patients, an increased risk of cardiovascular events, an increased risk of progression of chronic kidney disease (CKD) after AKI and a significantly increased long-term mortality. Despite the long-term impact of AKI, there are neither established guidelines on the follow-up care of AKI patients, nor treatment strategies to reduce the incidence of sequelae after AKI. Only a minority of patients have been referred to nephrology post-discharge care, despite the evidence of improved outcomes associated with nephrology referral by addressing cardiovascular risk and risk of progression to CKD. Indeed, AKI survivors should have specialized nephrology follow-up to assess kidney function after AKI, perform medication reconciliation, educate patients on nephrotoxic avoidance and implement strategies to prevent CKD progression. The authors provide a comprehensive review of the transition from AKI to CKD, analyse the current evidence on the long-term outcomes of AKI and describe predisposing risk factors, highlight the importance of follow-up care in these patients and describe the current therapeutic strategies which are being investigated on their impact in improving patient outcomes.
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http://dx.doi.org/10.1093/ckj/sfaa177DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7986368PMC
March 2021

EDTAKI: A Nephrology and Public Policy Committee (NPPC) Platform Call for More European Involvement in AKI.

Nephrol Dial Transplant 2021 Feb 2. Epub 2021 Feb 2.

Department of Nephrology, Ambroise Paré University Hospital, APHP, Boulogne-Billancourt/Paris, and Centre for Research in Epidemiology and Population Health (CESP), Paris-Saclay University, Versailles Saint Quentin University, INSERM UMRS 1018, Team5 Villejuif, France.

Acute Kidney Injury (AKI) is an often neglected but crucial element of clinical nephrology. The aim of the Nephrology Public Policy Committee (NPPC) of the European Renal Association - European Dialysis and Transplant Association (ERA-EDTA) is to promote several key aspects of European nephrology. One of the targets proposed by NPPC was to advance European nephrology involvement in AKI. We undertook literature analyses to define the current position of European nephrology in the field of AKI compared to other regions, and about how different European countries compare to each other. It appeared that vis-à-vis countries with a comparable socio-economic status (the US, Australia, New Zealand, Canada), the European contribution was almost 50% lower. Within Europe, Central/Eastern Europe and countries with a lower gross domestic product (GDP) showed lower scientific output. Nephrologists contributed to less than half of the output. There was no trend for a change over the last decade. It is concluded that there is room to improve the contribution of European nephrology in the field of AKI. We propose a model on how to promote clinical collaboration on AKI across Europe, the creation of a pan-European nephrology network of interested units is proposed, to improve clinical outcomes, increase nephrologist involvement and awareness outside nephrology, and stimulate research on AKI in Europe. Accordingly, we also propose a list of research priorities and stress the need for more European funding of AKI research.
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http://dx.doi.org/10.1093/ndt/gfab018DOI Listing
February 2021

The neutrophil-to-lymphocyte ratio as a marker of vasculitis activity, severe infection and mortality in anca-associated vasculitis: A retrospective study.

Nefrologia (Engl Ed) 2021 May-Jun;41(3):321-328. Epub 2020 Dec 11.

Division of Nephrology and Renal Transplantation, Department of Medicine. Centro Hospitalar Universitário Lisboa Norte, EPE. Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal.

Introduction: Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) is a multisystemic disease. Despite the improvement in mortality rate since the introduction of immunosuppression, long-term prognosis is still uncertain not only because of the disease activity but also due to treatment associated adverse effects. The neutrophil-to-lymphocyte ratio (NLR) has been demonstrated as an inflammatory marker in multiple settings. In this study, we aimed to investigate the prognostic ability of the NLR in AAV patients.

Methods: We conducted a retrospective analysis of the clinical records of all adult patients with AVV admitted to the Nephrology and Renal Transplantation Department of Centro Hospitalar Universitário Lisboa Norte from January 2006 to December 2019. NLR was calculated at admission. The outcomes measured were severe infection at 3 months and one-year mortality. The prognostic ability of the NLR was determined using the receiver operating characteristic (ROC) curve. A cut-off value was defined as that with the highest validity. All variables underwent univariate analysis to determine statistically significant factors that may have outcomes. Only variables which significantly differed were used in the multivariate analysis using the logistic regression method.

Results: We registered 45 cases of AVV. The mean age at diagnosis was 67.5±12.1 years and 23 patients were male. The mean Birmingham Vasculitis Activity Score (BVAS) at presentation was 26.0±10.4. Twenty-nine patients were ANCA-MPO positive, 7 ANCA-PR3 positive and 9 were considered negative ANCA vasculitis. At admission, mean serum creatinine (SCr) was 4.9±2.5mg/dL, erythrocyte sedimentation rate (ESR) was 76.9±33.8mm/h, hemoglobin was 9.5±1.7g/dL, C-reactive protein was 13.2±5.8mg/dL and NLR was 8.5±6.8. Thirty-five patients were treated with cyclophosphamide, eight patients with rituximab for induction therapy. Twenty patients developed severe infection within the first three months after starting induction immunosuppression. In a multivariate analysis, older age (73.6±10.5 vs. 62.6±11.3, p=0.002, adjusted OR 1.08 [95% CI 1.01-1.16], p=0.035) and higher NLR (11.9±7.4 vs. 5.9±5.0, p=0.002, adjusted OR 1.14 [95% CI 1.01-1.29], p=0.035) were predictors of severe infection at 3 months. NLR ≥4.04 predicted severe infection at 3 months with a sensitivity of 95% and specificity of 52% and the AUROC curve was 0.0794 (95% CI 0.647-0.900). Nine patients died within the first year. Severe infection at 3 months was independently associated with mortality within the first year (OR 6.19 [95% CI 1.12-34.32], p=0.037).

Conclusions: NLR at diagnosis was an independent predictor of severe infection within the first 3 months after immunosuppression start, and severe infection within the first three months was consequently correlated with one-year mortality. NLR is an easily calculated and low-cost laboratory inflammation biomarker and can prove useful in identifying AAV patients at risk of infection and poorer prognosis.
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http://dx.doi.org/10.1016/j.nefro.2020.07.013DOI Listing
December 2020

Atypical Hemolytic Uremic Syndrome and Nephrotic Syndrome Associated with Cytomegalovirus Infection.

Nephron 2021 8;145(2):188-191. Epub 2020 Dec 8.

Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal.

Atypical hemolytic uremic syndrome (aHUS) is a rare disease. It results from the dysregulation of the alternative complement pathway on the cell surface which causes endothelial damage. Increasing evidence links, these abnormalities to mutations in genes of complement regulators or with autoantibodies against complement factors. These mutations have an incomplete penetrance and variable phenotype. Cytomegalovirus (CMV) is endemic throughout the world, and the incidence of severe CMV disease in immunocompetent adults appears to be greater than previously thought. aHUS and nephrotic syndromes associated with CMV infection are rare. Identification of triggers for aHUS manifestation in a genetically susceptible patient is extremely important since this permits a faster initiation of treatment and clinical improvement. We report a case of a man with a homozygotic deletion of CFHR3-1 whose initial presentation was aHUS and nephrotic syndromes associated with CMV infection.
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http://dx.doi.org/10.1159/000511833DOI Listing
December 2020

Management of Acute Kidney Injury Following Major Abdominal Surgery: A Contemporary Review.

J Clin Med 2020 Aug 18;9(8). Epub 2020 Aug 18.

Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE. Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal.

Acute kidney injury (AKI) is a frequent occurrence following major abdominal surgery and is independently associated with both in-hospital and long-term mortality, as well as with a higher risk of progressing to chronic kidney disease (CKD) and cardiovascular events. Postoperative AKI can account for up to 40% of in-hospital AKI cases. Given the differences in patient characteristics and the pathophysiology of postoperative AKI, it is inappropriate to assume that the management after noncardiac and nonvascular surgery are the same as those after cardiac and vascular surgery. This article provides a comprehensive review on the available evidence on the management of postoperative AKI in the setting of major abdominal surgery.
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http://dx.doi.org/10.3390/jcm9082679DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7463962PMC
August 2020

Acute Kidney Injury: From Diagnosis to Prevention and Treatment Strategies.

J Clin Med 2020 Jun 2;9(6). Epub 2020 Jun 2.

Department of Medicine, Division of Nephrology and Renal Transplantation, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal.

Acute kidney injury (AKI) is characterized by an acute decrease in renal function that can be multifactorial in its origin and is associated with complex pathophysiological mechanisms. In the short term, AKI is associated with an increased length of hospital stay, health care costs, and in-hospital mortality, and its impact extends into the long term, with AKI being associated with increased risks of cardiovascular events, progression to chronic kidney disease (CKD), and long-term mortality. Given the impact of the prognosis of AKI, it is important to recognize at-risk patients and improve preventive, diagnostic, and therapy strategies. The authors provide a comprehensive review on available diagnostic, preventive, and treatment strategies for AKI.
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http://dx.doi.org/10.3390/jcm9061704DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7357116PMC
June 2020

Timing of Initiation of Renal Replacement Therapy in Sepsis-Associated Acute Kidney Injury.

J Clin Med 2020 May 10;9(5). Epub 2020 May 10.

Division of Nephrology and Renal Transplantation, Department of Medicine Centro Hospitalar Lisboa Norte, EPE Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal.

Sepsis-associated acute kidney injury (SA-AKI) is a major issue in medical, surgical and intensive care settings and is an independent risk factor for increased mortality, as well as hospital length of stay and cost. SA-AKI encompasses a proper pathophysiology where renal and systemic inflammation play an essential role, surpassing the classic concept of acute tubular necrosis. No specific treatment has been defined yet, and renal replacement therapy (RRT) remains the cornerstone supportive therapy for the most severe cases. The timing to start RRT, however, remains controversial, with early and late strategies providing conflicting results. This article provides a comprehensive review on the available evidence on the timing to start RRT in patients with SA-AKI.
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http://dx.doi.org/10.3390/jcm9051413DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7290350PMC
May 2020

Transient and Persistent AKI and Outcomes in Patients Undergoing Major Abdominal Surgery.

Nephron 2020 21;144(5):236-244. Epub 2020 Apr 21.

Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Lisbon, Portugal.

Introduction: Acute kidney injury (AKI) is a frequent diagnosis in surgical patients which has a detrimental effect on short-term and long-term outcomes. The purpose of this study was to evaluate the incidence and predictive factors of transient and persistent postoperative AKI in patients submitted to major abdominal surgery and to characterize the impact of AKI on in-hospital mortality.

Methods: This study was a cross-examination of a retrospective analysis of clinical data of 450 patients who underwent major abdominal surgery from January 2010 to February 2011. Only AKI developing in the first 48 h after surgery was considered. AKI was diagnosed using the Kidney Disease: Improving Global Outcome (KDIGO) classification based on both serum creatinine (SCr) and urine output criteria. Persistent and transient AKI were defined according to the Acute Disease Quality Initiative (ADQI) workgroup definitions.

Results: In our study, 22.4% of patients developed AKI in the first 48 h post-surgery (n = 101), and 48% of patients had persistent AKI (n = 49), defined as postoperative AKI, with a duration of more than 48 h. Older age (adjusted odds ratio [OR] 1.06 [1.00-1.11], p = 0.039), hypertension (adjusted OR 4.60 [1.17-18.11], p = 0.029), and higher preoperative SCr (adjusted OR 22.67 [4.00-128.46], p < 0.001) were independent predictors of persistent AKI. The overall in-hospital mortality was 6.4% (n = 29). Persistent AKI was associated with higher mortality than transient AKI (51.9 vs. 20.7%; unadjusted OR 13.03 [5.78-29.36], p < 0.001; adjusted OR 4.20 [1.02-17.27], p = 0.047).

Conclusion: In this cohort of patients submitted to major abdominal surgery, persistent AKI was an independent predictor of in-hospital mortality in contrast to transient AKI.
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http://dx.doi.org/10.1159/000506397DOI Listing
May 2021

Artificial Intelligence in Acute Kidney Injury Risk Prediction.

J Clin Med 2020 Mar 3;9(3). Epub 2020 Mar 3.

Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal.

Acute kidney injury (AKI) is a frequent complication in hospitalized patients, which is associated with worse short and long-term outcomes. It is crucial to develop methods to identify patients at risk for AKI and to diagnose subclinical AKI in order to improve patient outcomes. The advances in clinical informatics and the increasing availability of electronic medical records have allowed for the development of artificial intelligence predictive models of risk estimation in AKI. In this review, we discussed the progress of AKI risk prediction from risk scores to electronic alerts to machine learning methods.
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http://dx.doi.org/10.3390/jcm9030678DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141311PMC
March 2020

Neutrophil, lymphocyte and platelet ratio as a predictor of mortality in septic-acute kidney injury patients.

Nefrologia (Engl Ed) 2020 Jul - Aug;40(4):461-468. Epub 2020 Jan 13.

Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal.

Background: AKI is frequent in critically ill patients, in whom the leading cause of AKI is sepsis. The role of intrarenal and systemic inflammation appears to be significant in the pathophysiology of septic-AKI. The neutrophils to lymphocytes and platelets (N/LP) ratio is an indirect marker of inflammation. The aim of this study was to evaluate the prognostic ability of N/LP ratio at admission in septic-AKI patients admitted to an intensive care unit (ICU).

Methods: This is a retrospective analysis of 399 septic-AKI patients admitted to the Division of Intensive Medicine of the Centro Hospitalar Universitário Lisboa Norte between January 2008 and December 2014. The Kidney Disease Improving Global Outcomes (KDIGO) classification was used to define AKI. N/LP ratio was calculated as: (Neutrophil count×100)/(Lymphocyte count×Platelet count).

Results: Fifty-two percent of patients were KDIGO stage 3, 25.8% KDIGO stage 2 and 22.3% KDIGO stage 1. A higher N/LP ratio was an independent predictor of increased risk of in-hospital mortality in septic-AKI patients regardless of KDIGO stage (31.59±126.8 vs 13.66±22.64, p=0.028; unadjusted OR 1.01 (95% CI 1.00-1.02), p=0.027; adjusted OR 1.01 (95% CI 1.00-1.02), p=0.015). The AUC for mortality prediction in septic-AKI was of 0.565 (95% CI (0.515-0.615), p=0.034).

Conclusions: The N/LP ratio at ICU admission was independently associated with in-hospital mortality in septic-AKI patients.
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http://dx.doi.org/10.1016/j.nefro.2019.11.006DOI Listing
January 2020

Complete blood count in acute kidney injury prediction: a narrative review.

Ann Intensive Care 2019 Aug 6;9(1):87. Epub 2019 Aug 6.

Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal.

Acute kidney injury (AKI) is a complex syndrome defined by a decrease in renal function. The incidence of AKI has raised in the past decades, and it is associated with negative impact in patient outcomes in the short and long term. Considering the impact of AKI on patient prognosis, research has focused on methods to assess patients at risk for developing AKI, diagnose subclinical AKI, and on prevention and treatment strategies, for which it is crucial an understanding of pathophysiology the of AKI. In this review, we discuss the use of easily available parameters found in a complete blood count to detect patients at risk for developing AKI, to provide an early diagnosis of AKI, and to predict associated patient outcomes.
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http://dx.doi.org/10.1186/s13613-019-0561-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6684666PMC
August 2019

Uremic lion face syndrome.

J Bras Nefrol 2019 Apr-Jun;41(2):304-305. Epub 2019 Jan 21.

Centro Hospitalar Lisboa Norte EPE, Serviço de Nefrologia e Transplantação Renal, Lisboa, Portugal.

Mineral bone disorder is a common feature of chronic kidney disease. Lion face syndrome is rare complication of severe hyperparathyroidism in end-stage renal disease patients, which has been less commonly reported due to dialysis and medical treatment advances in the last decade. The early recognition of the characteristic facial deformity is crucial to prompt management and prevent severe disfigurement. The authors present a rare case of severe hyperparathyroidism presenting with lion face syndrome and bone fractures.
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http://dx.doi.org/10.1590/2175-8239-JBN-2018-0198DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6699430PMC
February 2020

Transient and persistent acute kidney injury in acute liver failure.

J Nephrol 2019 Apr 19;32(2):289-296. Epub 2018 Dec 19.

Division of Nephrology and Renal Transplantation, Department of Medicina, Centro Hospitalar Lisboa Norte, EPE, Lisboa, Portugal.

Background: Acute Kidney Injury (AKI) is a very frequent complication in the Acute Liver Failure (ALF) population associated with negative outcomes. We aim to evaluate the impact of AKI duration on the outcomes of an ALF population.

Methods: A 20-year retrospective analysis of ALF patients admitted to an Intensive Care Unit (ICU) was performed. Chronic liver failure, chronic kidney disease on renal replacement therapy, dialysis requirement within the week prior or an ICU stay of less than 48 h after AKI diagnosis, were exclusion criteria. AKI was defined according to the KDIGO criteria and classified into transient (< 48 h duration) or persistent (48 h duration).

Results: A total of 51 patients were included in the analysis and most had AKI (66.7%). Persistent AKI patients (70.6%) presented more frequently with AKI at admission and a higher SOFA score than transient AKI and no AKI, p < 0.05. More severe AKI, sepsis, vasopressor support and mechanical ventilation were also more common (p < 0.05). Nineteen (55.9%) were classified as persistent AKI exclusively by serum creatinine and 15 (44.1%) by both serum creatinine and urine output criteria. Mean survival time at 30 days was 11.3 days for persistent AKI, 25.3 days for transient AKI and 27.0 days for no AKI, p = 0.01. Adjusted multivariate cox regression analysis showed that persistent AKI predicted in-hospital mortality but it lost significance when AKI severity was introduced in the model.

Conclusion: Persistent AKI was common in ALF patients and associated with more severe AKI, worst systemic complications and a higher 30-day mortality, compared to transient and no AKI patients.
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http://dx.doi.org/10.1007/s40620-018-00568-wDOI Listing
April 2019

Neutrophil, lymphocyte and platelet ratio as a predictor of postoperative acute kidney injury in major abdominal surgery.

BMC Nephrol 2018 11 12;19(1):320. Epub 2018 Nov 12.

Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal.

Background: Surgery is one of the leading causes of acute kidney injury (AKI) in hospitalized patients. Major abdominal surgery has the second higher incidences of AKI, after cardiac surgery. AKI results from a complex interaction between hemodynamic, toxic and inflammatory factors. The pathogenesis of AKI following major abdominal surgery is distinct from cardiac and vascular surgery. The neutrophil, lymphocytes and platelets (N/LP) ratio has been demonstrated as an inflammatory marker and an independent predictor for AKI and mortality after cardiovascular surgery. The aim of this study was to evaluate the prognostic ability of the post-operative N/LP ratio after major abdominal surgery.

Methods: We cross-examined data of a retrospective analysis of 450 patients who underwent elective or urgent major nonvascular abdominal surgery at the Department of Surgery II of Centro Hospitalar Lisboa Norte from January 2010 to February 2011. N/LP ratio was determined using maximal neutrophil counts and minimal lymphocyte and platelet counts in the first 12 h after surgery. AKI was considered when developed within 48 h after surgery.

Results: One-hundred and one patients (22.4%) developed AKI. Patients with higher N/LP ratio had an increased risk of developing postoperative AKI (6.36 ± 7.34 vs 4.33 ± 3.36, p < 0.001; unadjusted OR 1.1 (95% CI 1.04-1.16), p = 0.001; adjusted OR 1.05 (95% CI 1.00-1.10), p = 0.048). Twenty-nine patients died (6.44%). AKI was an independent predictor of mortality (20.8 vs 2.3%, p < 0.0001; unadjusted OR 11.2, 95% CI 4. 8-26.2, p < 0.0001; adjusted OR 3.56, 95% CI 1.0 2-12.43, p = 0.046). In a multivariate analysis higher N/LP ratio was not associated with increased in-hospital mortality.

Conclusion: Postoperative N/LP ratio was independently associated with AKI after major abdominal surgery, although there was no association with in-hospital mortality.
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http://dx.doi.org/10.1186/s12882-018-1073-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6231266PMC
November 2018

Acute Kidney Injury Definition and Diagnosis: A Narrative Review.

J Clin Med 2018 Sep 28;7(10). Epub 2018 Sep 28.

Division of Nephrology and Renal Transplantation, Department of Medicine Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal.

Acute kidney injury (AKI) is a complex syndrome characterized by a decrease in renal function and associated with numerous etiologies and pathophysiological mechanisms. It is a common diagnosis in hospitalized patients, with increasing incidence in recent decades, and associated with poorer short- and long-term outcomes and increased health care costs. Considering its impact on patient prognosis, research has focused on methods to assess patients at risk of developing AKI and diagnose subclinical AKI, as well as prevention and treatment strategies, for which an understanding of the epidemiology of AKI is crucial. In this review, we discuss the evolving definition and classification of AKI, and novel diagnostic methods.
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http://dx.doi.org/10.3390/jcm7100307DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6211018PMC
September 2018

Haemodialysis-related-heparin-induced thrombocytopenia: Case series and literature review.

Nefrologia (Engl Ed) 2018 Sep - Oct;38(5):551-557. Epub 2018 Jun 2.

Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal.

Heparin-induced thrombocytopenia (HIT) is a serious and life-threatening complication that occurs in five per cent of patients exposed to heparin. It should be considered in patients with a platelet count <100×10cells/l or a >50% decrease from baseline count in association with heparin therapy. Thromboembolic complications develop in 50% of patients. Bleeding is rare as the platelet count nadir typically does not drop below 20×10cells/l. Up to 12% of dialysis patients develop HIT, named haemodialysis-related-heparin-induced thrombocytopenia (HD-HIT), as they are a risk group with continuous exposure to heparin. The definition of HD-HIT is less strict, in the range of a platelet count decrease of 30% and below 150×10cells/l due to the intermittent use of heparin. Heparin cessation and alternative anticoagulation are the key interventions in patients with HIT. In dialysis patients, citrate anticoagulation, heparin-free dialysis or peritoneal dialysis are options that must be considered. The authors describe the presentation, diagnosis, treatment and outcomes of five cases of HD-HIT, and emphasize the importance of an accurate diagnosis and early intervention in order to reduce the mortality risk, which can be as high as 20 per cent.
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http://dx.doi.org/10.1016/j.nefro.2018.02.010DOI Listing
October 2019

Acute Kidney Injury.

Ann Intern Med 2018 06;168(11):836-837

Centro Hospitalar Lisboa Norte, Lisbon, Portugal (J.G., S.J., J.A.L.).

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http://dx.doi.org/10.7326/L18-0015DOI Listing
June 2018

Prediction of acute kidney injury in cirrhotic patients: a new score combining renal, liver and inflammatory markers.

Int J Nephrol Renovasc Dis 2018 24;11:149-154. Epub 2018 Apr 24.

Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, Lisboa, Portugal.

Introduction: Acute kidney injury (AKI) is common in hospitalized patients with cirrhosis and is associated with poor prognosis. A risk prediction score combining values easily measured at admission could be valuable to stratify patients for prevention, monitoring and early intervention, ultimately improving patient care and outcomes. The aim of this study was to develop a risk score for AKI in a cohort of cirrhotic patients.

Patients And Methods: We cross-examined the data from a retrospective analysis of 186 patients with cirrhosis admitted to the Gastroenterology and Hepatology Service of Centro Hospitalar Lisboa Norte from January 2003 to December 2005. AKI was defined as an increase in serum creatinine (SCr)≥0.3 mg/dL within 48 hours or a percentage increase in SCr≥50% from baseline. Neutrophil-to-lymphocyte ratio (NLR) was used as a marker for inflammation. A receiver operating characteristic (ROC) curve was produced to assess the discriminative ability of the variables. Cutoff values were defined as those with highest validity. The final AKI risk score model was assessed using the ROC curve.

Results: A total of 52 patients (28%) developed AKI. Higher baseline SCr (<0.001), more severe liver disease as evaluated by the modified Model of End-stage Liver Disease (MELD)-Na score (<0.001) and higher NLR (=0.028) were independently associated with AKI. The area under the ROC (AUROC) curve for the prediction of AKI was 0.791 (95% CI 0.726-0.847) for SCr, 0.771 (95% CI 0.704-0.829) for modified MELD-Na and 0.757 (95% CI 0.689-0.817) for NLR. Cutoff values with the highest validity for predicting AKI were determined and defined as 0.9 for the SCr, 21.7 for the modified MELD-Na and 6 for the NLR. The risk score was created allowing 3 points if the SCr is higher than 0.9, 1 point if the modified MELD-Na is higher than 21.7 and 1 point if the NLR is higher than 6. The AUROC curve of the risk prediction score for AKI was 0.861. A risk score of ≥2 points predicts AKI in cirrhotic patients with a sensitivity of 88.5% and specificity of 72.4%.

Conclusion: A new score combining SCr, MELD-Na and NLR demonstrated a strong discriminative ability to predict AKI in cirrhotic patients.
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http://dx.doi.org/10.2147/IJNRD.S163602DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5923222PMC
April 2018

Acute kidney injury in major abdominal surgery: incidence, risk factors, pathogenesis and outcomes.

Ann Intensive Care 2018 Feb 9;8(1):22. Epub 2018 Feb 9.

Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal.

Acute kidney injury (AKI) is a common complication in patients undergoing major abdominal surgery. Various recent studies using modern standardized classifications for AKI reported a variable incidence of AKI after major abdominal surgery ranging from 3 to 35%. Several patient-related, procedure-related factors and postoperative complications were identified as risk factors for AKI in this setting. AKI following major abdominal surgery has been shown to be associated with poor short- and long-term outcomes. Herein, we provide a contemporary and critical review of AKI after major abdominal surgery focusing on its incidence, risk factors, pathogeny and outcomes.
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http://dx.doi.org/10.1186/s13613-018-0369-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5807256PMC
February 2018

Can We Really Discuss About RRT Starting Time Before We Have a Recovery Biomarker?

J Intensive Care Med 2018 03;33(3):218

3 Division of Nephrology and Renal Transplantation, Department of Medicina, Centro Hospitalar Lisboa Norte, EPE, Lisboa, Portugal.

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http://dx.doi.org/10.1177/0885066617722121DOI Listing
March 2018

Obesity, acute kidney injury and mortality in patients with sepsis: a cohort analysis.

Ren Fail 2018 Nov;40(1):120-126

a Division of Nephrology and Renal Transplantation, Department of Medicine , Centro Hospitalar Lisboa Norte, EPE , Lisboa , Portugal.

Although the prognostic effect of obesity has been studied in critically ill patients its impact on outcomes of septic patients and its role as a risk factor for acute kidney injury (AKI) is not consensual. We aimed to analyze the impact of obesity on the occurrence of AKI and on in-hospital mortality in a cohort of critically ill septic patients. This study is retrospective including 456 adult patients with sepsis admitted to the Division of Intensive Medicine of the Centro Hospitalar Lisboa Norte (Lisbon, Portugal) between January 2008 and December 2014. Obesity was defined as a body mass index of 30 kg/m or higher. The Kidney Disease Improving Global Outcomes classification was used to diagnose and classify patients developing AKI. AKI occurred in 87.5% of patients (19.5% with stage 1, 22.6% with stage 2 and 45.4% with stage 3). Obese patients developed AKI more frequently than non-obese patients (92.8% versus 85.5%, p = .035; unadjusted OR 2.2 (95% CI: 1.04-4.6), p = .039; adjusted OR 2.31 (95% CI: 1.07-5.02), p = .034). The percentage of obese patients, however, did not differ between AKI stages (stage 1, 25.1%; stage 2, 28.6%; stage 3, 15.4%; p = .145). There was no association between obesity and mortality (p = .739). Of note, when comparing AKI patients with or without obesity in terms of in-hospital mortality there were also no significant differences between those groups (38.4% versus 38.4%, p = .998). Obesity was associated with the occurrence of AKI in critically ill patients with sepsis; however, it was not associated with in-hospital mortality.
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http://dx.doi.org/10.1080/0886022X.2018.1430588DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6014496PMC
November 2018

Diabetes, deafness and renal disease.

Clin Kidney J 2017 Aug 28;10(4):487-489. Epub 2017 Mar 28.

Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Lisboa, Portugal.

Deafness, kidney disease and diabetes are not a usual association, neither is a family history of these diseases. We present the case of a 47-year-old woman with non-nephrotic proteinuria, no haematuria, normal renal function, sensorineural hearing loss, recently diagnosed diabetes and maculopathy. There was a maternal family history of deafness, diabetes and renal disease. Renal biopsy revealed focal and segmental glomerulosclerosis (FSGS), leading to the pursuit of an m.3243A > G mitochondrial mutation and diagnosis of maternally inherited diabetes and deafness. The association of FSGS with mitochondrial diseases is not well known among nephrologists. Its timely diagnosis is important to avoid exposure to ineffective and unnecessary immunosuppression.
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http://dx.doi.org/10.1093/ckj/sfx021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5569948PMC
August 2017

Acute kidney injury in patients with severe sepsis or septic shock: a comparison between the 'Risk, Injury, Failure, Loss of kidney function, End-stage kidney disease' (RIFLE), Acute Kidney Injury Network (AKIN) and Kidney Disease: Improving Global Outcomes (KDIGO) classifications.

Clin Kidney J 2017 Jun 13;10(3):332-340. Epub 2016 Dec 13.

Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, Lisboa, Portugal.

Purpose: Using the Risk, Injury, Failure, Loss of kidney function, End-stage kidney disease (RIFLE), Acute Kidney Injury Network (AKIN) and Kidney Disease: Improving Global Outcomes (KDIGO) systems, the incidence of acute kidney injury (AKI) and their ability to predict in-hospital mortality in severe sepsis or septic shock was compared.

Materials And Methods: We performed a retrospective analysis of 457 critically ill patients with severe sepsis or septic shock hospitalized between January 2008 and December 2014. Multivariate logistic regression was employed to evaluate the association between the RIFLE, AKIN and KDIGO systems with in-hospital mortality. Model fit was assessed by the goodness-of-fit test and discrimination by the area under the receiver operating characteristic (AUROC) curve. Statistical significance was defined as P < 0.05.

Results: RIFLE (84.2%) and KDIGO (87.5%) identified more patients with AKI than AKIN (72.8%) (P < 0.001). AKI defined by AKIN and KDIGO was associated with in-hospital mortality {AKIN: adjusted odds ratio [OR] 2.3[95% confidence interval (CI) 1.3-4], P = 0.006; KDIGO: adjusted OR 2.7[95% CI 1.2-6.2], P = 0.021} while AKI defined by RIFLE was not [adjusted OR 2.0 (95% CI 1-4), P = 0.063]. The AUROC curve for in-hospital mortality was similar between the three classifications (RIFLE 0.652, P < 0.001; AKIN 0.686, P < 0.001; KDIGO 0.658, P < 0.001).

Conclusions: RIFLE and KDIGO diagnosed more patients with AKI than AKIN, but the prediction ability for in-hospital mortality was similar between the three systems.
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http://dx.doi.org/10.1093/ckj/sfw107DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5466088PMC
June 2017

Pulmonary-renal syndrome as a clinical expression of multiple myeloma.

Nefrologia 2017 Jul - Aug;37(4):445-446. Epub 2017 Jan 2.

Service of Nephrology and Renal Transplantation, Department of Medicine Centro Hospitalar Lisboa Norte, EPE Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal.

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http://dx.doi.org/10.1016/j.nefro.2016.10.020DOI Listing
January 2017

Acute kidney injury, long-term renal function and mortality in patients undergoing major abdominal surgery: a cohort analysis.

Clin Kidney J 2016 Apr 18;9(2):192-200. Epub 2016 Jan 18.

Department of Medicine , Service of Nephrology and Renal Transplantation , Lisboa , Portugal.

Background: Acute kidney injury (AKI) is frequent during hospitalization and may contribute to adverse consequences. We aimed to evaluate long-term adverse renal function and mortality after postoperative AKI in a cohort of patients undergoing major abdominal surgery.

Methods: We performed a retrospective analysis of adult patients who underwent major non-vascular abdominal surgery between January 2010 and February 2011 at the Department of Surgery II of Hospital de Santa Maria-Centro Hospitalar Lisboa Norte, Portugal. Exclusion criteria were as follows: chronic kidney disease on renal replacement therapy, undergoing renal replacement therapy the week before surgery, death before discharge and loss to follow-up through January 2014. Patients were categorized according to the development of postoperative AKI in the first 48 h after surgery using the Kidney Disease: Improving Global Outcomes classification. AKI was defined by an increase in absolute serum creatinine (SCr) ≥0.3 mg/dL or by a percentage increase in SCr ≥50% and/or by a decrease in urine output to <0.5 mL/kg/h for >6 h. Adverse renal outcomes (need for long-term dialysis and/or a 25% decrease in estimated glomerular filtration rate after hospital discharge) and mortality after discharge were evaluated. Cumulative mortality was analysed with the Kaplan-Meier method and log-rank test and outcome predictive factors with the Cox regression. Significance was set at P < 0.05.

Results: Of 390 selected patients, 72 (18.5%) developed postoperative AKI. The median follow-up was 38 months. Adverse renal outcomes and death after hospital discharge were more frequent among AKI patients (47.2 versus 22.0%, P < 0.0001; and 47.2 versus 20.5%, P < 0.0001, respectively). The 4 year cumulative probability of death was 44.4% for AKI patients, while it was 19.8% for patients with no AKI (log-rank test, P < 0.0001). In multivariate analysis, AKI was a risk factor for adverse renal outcomes (adjusted hazard ratio 1.6, P = 0.046) and mortality (adjusted hazard ratio 1.4, P = 0.043).

Conclusions: AKI after major abdominal surgery was independently associated with the risk of long-term need for dialysis and/or renal function decline and with the risk of death after hospital discharge.
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http://dx.doi.org/10.1093/ckj/sfv144DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4792619PMC
April 2016

Extended daily dialysis versus intermittent hemodialysis for acute kidney injury: A systematic review.

J Crit Care 2016 06 9;33:271-3. Epub 2016 Feb 9.

Service of Nephrology and Renal Transplantation, Centro Hospitalar Lisboa Norte, Portugal. Electronic address:

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http://dx.doi.org/10.1016/j.jcrc.2016.02.001DOI Listing
June 2016
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