Alejandro Ferreiro

Introduction: Socioeconomic and developmental diversity across Latin America (LA) significantly affects the availability of extracorporeal blood purification (EBP) therapies to treat acute kidney injury (AKI) and the training of nephrology fellows in these technologies. This survey assessed the availability of EBP therapies and perceived training needs of nephrologists and intensivists in the region. Objective: The aim of this study was to evaluate the availability of EBP therapies to treat AKI and identify training needs among LA nephrologists and intensivists. Methods: Between March and December 2024, the AKI and extracorporeal organ support therapy committee of SLANH conducted an online survey targeting nephrologists and intensivists. The survey gathered data on the availability of EBP technologies in their institutions and perceived training needs. Results: A total of 505 responses were collected, with 93% submitted by nephrologists. Participants represented 20 LA countries, primarily from South America (58%), Mexico (23.6%), and the Caribbean (10.1%). Intermittent hemodialysis (IHD) was the most widely available therapy, accessible in 98% of centers. Peritoneal dialysis (PD) was available in 65% of hospitals, while continuous renal replacement therapy (CRRT) in 59% of centers but reported as unavailable in Haiti, Nicaragua, Paraguay, and Venezuela. Therapeutic plasma exchange (TPE) was available in 60% of hospitals, although accessibility varied significantly by country. Multi-organ support therapies showed limited regional availability, including liver support (11.9%), extracorporeal membrane oxygenation (ECMO, 16.7%), extracorporeal CO2 removal (ECCO2R, 7%), and hemoadsorption (20.6%). The greatest perceived training needs were identified for ECMO (54.2%), ECCO2R (51.3%), CRRT (48.7%), and TPE (46.8%), whereas demand for further training in IHD and PD was comparatively lower. These findings underscore substantial disparities in therapy access and highlight urgent regional priorities for advanced EBP training. Conclusion: This study highlights significant disparities in EBP therapy availability across LA, with advanced modalities such as CRRT and multi-organ support largely inaccessible in several countries. Additionally, there is a high perceived need for training in ECMO, ECCO2R, CRRT, and TPE. Addressing these gaps requires expanding access to EBP, implementing standardized training programs, establishing regional centers of excellence, and fostering international collaboration. Policy advocacy and increased resource allocation will be essential to improving access and optimizing patient outcomes across the region.

Resumo Introdução: A doença renal aguda (DRA) é definida como anormalidades renais funcionais e/ou estruturais, com implicações para saúde e duração ≤90 dias. O objetivo foi avaliar a DRA como uma abordagem mais apropriada para essas condições, utilizando uma coorte com COVID-19, onde o comprometimento renal é expresso por proteinúria e/ou perda de função. Métodos: Estudo de coorte observacional, prospectivo, longitudinal, multinacional realizado em cinco países latino-americanos. Foram incluídos pacientes adultos com diagnóstico de COVID-19. Na internação, realizou-se urinálise ou teste de urina com tira reagente. Caso a proteína não fosse detectada, uma investigação de acompanhamento era feita cinco dias depois. Os pacientes foram classificados em quatro categorias de DRA: doença não renal, somente proteinúria, somente injúria renal aguda (IRA), proteinúria e IRA. Resultados: Foram incluídos 360 pacientes. A DRA esteve presente em 273 (75,8%), dos quais 142 (52,0%) apresentaram somente proteinúria, 11 (4,1%) IRA sem proteinúria e 120 (43,9%) apresentaram proteinúria e IRA. No geral, a proteinúria, com ou sem IRA, foi observada em 262 pacientes (72,8%). A IRA, com ou sem proteinúria, ocorreu em 131 pacientes (36,4%). A IRA foi predominantemente grave, não oligúrica e adquirida no hospital. A mortalidade hospitalar aumentou com a gravidade da DRA: doença não renal 9,5%, somente proteinúria 22,8%, somente IRA 56,7%, proteinúria mais IRA 53,0% (p = 0,001). Conclusões: Nossos dados endossam uma abordagem abrangente baseada no conceito de DRA. Essa abordagem integrativa, englobando o continuum estrutural e funcional de IRA, DRA e DRC, permite intervenções oportunas e a implementação de estratégias preventivas e terapêuticas.

Introduction: Acute kidney disease (AKD) is defined as functional and/or structural abnormalities of kidneys with health implications and a duration of ≤90 days. This study aimed to evaluate AKD as a more appropriate approach to these conditions for which we used a cohort of COVID-19 patients in whom kidney impairment is expressed by proteinuria and/or loss of function. Methods: Observational, prospective, longitudinal, multinational cohort study conducted across five Latin American countries. Adult patients with diagnosis of COVID-19 were included. Upon hospital admission, urinalysis or urine strip test was performed. If protein was not detected, a follow-up search was conducted five days later. Patients were classified in four AKD categories: non-kidney disease, proteinuria only, acute kidney injury (AKI) only, and proteinuria and AKI. Results: Three hundred and sixty patients were included. AKD was present in 273 (75.8%), of whom 142 (52.0%) had only proteinuria, 11 (4.1%) had AKI without proteinuria, and 120 (43.9%) had both proteinuria and AKI. Overall, proteinuria with or without AKI was present in 262 patients (72.8%). AKI with or without proteinuria occurred in 131 patients (36.4%). AKI was mainly severe, non-oliguric, and hospital-acquired. In-hospital mortality increased with the severity of AKD: non-kidney disease 9.5%, proteinuria only 22.8%, AKI only 56.7%, and proteinuria plus AKI 53.0% (p = 0.001). Conclusions: Our data endorse a comprehensive approach based on the concept of AKD. This integrative approach, encompassing the structural and functional continuum of AKI, AKD, and CKD, enables timely interventions and the implementation of preventive and therapeutic strategies.

Introduction: Life participation is of critical importance to patients with chronic kidney disease (CKD) not requiring kidney replacement therapy (KRT), their caregivers and health professionals. However, life participation is rarely and inconsistently assessed in trials in CKD. The aim was to establish a core outcome measure for life participation in patients with CKD not requiring KRT. Methods: An online (English language) and an in-person (Spanish language) consensus workshop, one-hour in length, were held in March and April 2024 respectively, were held to discuss and establish a meaningful, relevant and feasible core patient-reported outcome measure for life participation for trials in CKD. Transcripts were analyzed thematically. Results: Workshops included 130 participants, including 74 patients and caregivers, and 56 health professionals, from 18 countries. Four themes were identified. Enabling interpretation within individual contexts and circumstances included considering relevance to patients’ own priorities, capturing key life activities common to all patients, reflecting the goal of leading a fulfilling life, acknowledging the variability and multiplicity of domains, and facilitating linguistic and cultural translation. Having broad clinical relevance across CKD meant covering the spectrum of CKD stages and diagnoses, and allowing comparison across treatment stages. Supporting widespread implementation entailed minimizing burden of administration and completion, establishing psychometric robustness, seeking endorsement to legitimize the measure, and ensuring accessibility and acceptability across different settings. Highlighting opportunities to address life participation captured promoting person-centered clinical care and generating ideas for novel interventions to improve life participation. Conclusion: A core outcome measure for life participation in patients with CKD should enable a patient to interpret life participation in their own context, have applicability across the CKD population, and be psychometrically robust and feasible to implement. Measuring life participation in a consistent and meaningful way across trials can better support patient-centered decision making and outcomes.

Background: HEARTS in the Americas is the regional adaptation of the WHO Global HEARTS Initiative, aimed at helping countries enhance hypertension and cardiovascular disease (CVD) risk management in primary care settings. Its core implementation tool, the HEARTS Clinical Pathway, has been adopted by 28 countries. To improve the care of hypertension, diabetes, and chronic kidney disease (CKD), HEARTS 2.0 was developed as a three-phase process to integrate evidence-based interventions into a unified care pathway, ensuring consistency across fragmented guidelines. This paper focuses on Phase 1, highlighting targeted interventions to improve and update the HEARTS Clinical Pathway. Methods: First, the coordinating group defined the project’s scope, objectives, principles, methodological framework, and tools. Second, international experts from different disciplines proposed interventions to enhance the HEARTS Clinical Pathway. Third, the coordinating group harmonized these proposals into unique interventions. Fourth, experts appraised the appropriateness of the proposed interventions on a 1-to-9 scale using the adapted RAND/UCLA Appropriateness Method. Finally, interventions with a median score above 6 were deemed appropriate and selected as candidates to enhance the HEARTS Clinical Pathway. Results: Building on the existing HEARTS Clinical Pathway, 45 unique interventions were selected, including community-based screening, early detection and management of risk factors, lower blood pressure thresholds for diagnosing hypertension in high-CVD-risk patients, reinforcement of single-pill combination therapy, inclusion of sodium-glucose cotransporter-2 inhibitors for patients with diabetes, CKD, or heart failure, expanded roles for non-physician health workers in team-based care, and strengthened clinical documentation, monitoring, and evaluation. Conclusion: HEARTS 2.0 Phase 1 identifies key interventions to integrate and improve hypertension and cardiovascular-kidney-metabolic care within primary care, enabling their seamless incorporation into a unified and effective clinical pathway. This process will inform an update to the HEARTS Clinical Pathway, optimizing resources, reducing care fragmentation, improving care delivery, and advancing health equity, thereby supporting global efforts to combat the leading causes of death and disability.

Introduction: The Renal Healthcare Program Uruguay (NRHP-UY) is a national, multidisciplinary program that provides care to chronic kidney disease (CKD) patients. In this study, we report the global results of CKD patient outcomes and a comparison between those treated at the NRHP-UY Units, with those patients who were initially included in the program but did not adhere to follow up. Methods: A cohort of not-on dialysis CKD patients included prospectively in the NRHP-UY between October 1^st 2004 and September 30^th 2017 was followed-up until September 30^th 2019. Two groups were compared: a) Nephrocare Group: Patients who had at least one clinic visit during the first year on NRHP-UY (n = 11174) and b) Non-adherent Group: Patients who were informed and accepted to be included but had no subsequent data registered after admission (n = 3485). The study was approved by the Ethics Committee and all patients signed an informed consent. Outcomes were studied with Logistic and Cox´s regression analysis, Fine and Gray competitive risk and propensity-score matching tests. Results: 14659 patients were analyzed, median age 70 (60–77) years, 56.9% male. The Nephrocare Group showed improved achievement of therapeutic goals, ESKD was more frequent (HR 2.081, CI 95%1.722–2.514) as planned kidney replacement therapy (KRT) start (OR 2.494, CI95% 1.591–3.910), but mortality and the combined event (death and ESKD) were less frequent (HR 0.671, CI95% 0.628–0.717 and 0.777, CI95% 0.731–0.827) (p = 0.000) compared to the Non-adherent group. Results were similar in the propensity-matched group: ESKD (HR 2.041, CI95% 1.643–2.534); planned kidney replacement therapy (KRT) start (OR 2.191, CI95% 1.322–3.631) death (HR 0.692, CI95% 0.637–0.753); combined event (HR 0.801, CI95% 0.742–0.865) (p = 0.000). Conclusion: Multidisciplinary care within the NRHP-UY is associated with timely initiation of KRT and lower mortality in single outcomes, combined analysis, and propensity-matched analysis.

The Latin American Society of Nephrology and Hypertension conducted a prospective cohort, multinational registry of Latin American patients with kidney impairment associated to COVID-19 infection with the objective to describe the characteristics of acute kidney disease under these circumstances. The study was carried out through open invitation in order to describe the characteristics of the disease in the region. Eight-hundred and seventy patients from 12 countries were included. Median age was 63 years (54–74), most of patients were male (68.4%) and with diverse comorbidities (87.2%). Acute kidney injury (AKI) was hospital-acquired in 64.7% and non-oliguric in 59.9%. Multiorgan dysfunction syndrome (MODS) due to COVID-19 and volume depletion were the main factors contributing to AKI (59.2% and 35.7% respectively). Kidney replacement therapy was started in 46.2%. Non-recovery of renal function was observed in 65.3%. 71.5% of patients were admitted to ICU and 72.2% underwent mechanical ventilation. Proteinuria at admission was present in 62.4% of patients and proteinuria during hospital-stay occurred in 37.5%. Those patients with proteinuria at admission had higher burden of comorbidities, higher baseline sCr, and MODS was severe. On the other hand, patients with de novo proteinuria had lower incidence of comorbidities and near normal sCr at admission, but showed adverse course of disease. COVID-19 MODS was the main cause of AKI in both groups. All-cause mortality of the general population was 57.4%, and it was associated to age, sepsis as cause of AKI, severity of condition at admission, oliguria, mechanical ventilation, non-recovery of renal function, in-hospital complications and hospital stay. In conclusion, our study contributes to a better knowledge of this condition and highlights the relevance of the detection of proteinuria throughout the clinical course.