Renal function and cognitive dysfunction: cross-sectional study of users
               enrolled at ponte-family health unit

Antunes, João Pedro Vieira; Bulhões, Cláudia; Fonte, Pedro; Abreu, Mafalda Jordão; Oliveira, Rui

doi:10.5935/0101-2800.20150012

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Brazilian Journal of Nephrology

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Sumário

• J Bras Nefrol 37 (1) • Jan-Mar 2015 • https://doi.org/10.5935/0101-2800.20150012 copy

Renal function and cognitive dysfunction: cross-sectional study of users enrolled at ponte-family health unit

Authorship SCIMAGO INSTITUTIONS RANKINGS

Introduction:

Recent studies show increased prevalence of Cognitive Dysfunction in patients with Chronic Kidney Disease.

Objective:

To evaluate this association in users enrolled in the Family Health Unit Ponte.

Methods:

We studied a sample of 246 elderly. We assessed cognitive function using the Mini Mental State Examination and the Glomerular Filtration Rate using the equation Modification of Diet in Renal Disease. The Glomerular Filtration Rate values obtained (ml/min/1,73 m²) were divided into three categories: < 60.00, 60 to 89.99 and ≥ 90. We collected additional variables from the Medical Support Service and studied the data using bivariate analyzes and logistic regression models.

Results:

The groups with Glomerular Filtration Rate < 60 and ≥ 90 had a higher prevalence of Cognitive Dysfunction, irrespective of other factors. The odds ratios were, respectively, of 4.534 (95%CI: 1.257 to 16.356) and 3.302 (95% CI: 1.434 to 7.607).

Discussion:

According to the literature, we found higher prevalence of Cognitive Dysfunction in the group with Glomerular Filtration Rate < 60. The high prevalence of Cognitive Dysfunction in users with GFR ≥ 90 is described in some studies and may be caused by situations that lead to overestimation of that rate, as the states of cachexia, or situations of glomerular hyperfiltration.

Conclusion:

The relationship between renal function and the prevalence of Cognitive Dysfunction was not linear, but rather in a parabolic shape. Further studies are needed to explain this relationship and to determine the need for monitoring Cognitive Dysfunction in patients with impaired renal function.

glomerular filtration rate; kidney function tests; mild cognitive impairment; renal insufficiency, chronic

Variables		GFR groups (ml/min/1.73 m2)		Pearson Chisquare/ Fisher exact test	Kruskal-Wallis	Exact Sig.(2-sided)
	< 60,00	60,00-89,99	≥ 90,00
Absolute frequency	23	103	120	-	-	-
Gender (female)	78,3%^¶ ¶ ρ ≤ 0,05;	52,4%^* * Reference group(s); BMI: Body mass index; BP: Blood pressure; GFR: Glomerular filtration rate; Hx: History; CVD: Cardiovascular disease; HADS-B: Hospital Anxiety and Depression Scale domain B;	48,3%^* * Reference group(s); BMI: Body mass index; BP: Blood pressure; GFR: Glomerular filtration rate; Hx: History; CVD: Cardiovascular disease; HADS-B: Hospital Anxiety and Depression Scale domain B;	6,950	-	0,031
Age^§ § Metric variables, represented by mean values and standard deviation between brackets.	75,70^¶ ¶ ρ ≤ 0,05; (5,61)	72,64 (5,22)	71,22* (5,17)	-	14,643	0,001
Years of education^§ § Metric variables, represented by mean values and standard deviation between brackets.	2,17 (1,69)	3,14 (2,93)	3,38 (2,56)	-	5,754	0,056
BMI^§ § Metric variables, represented by mean values and standard deviation between brackets.	29,76 (5,31)	28,095 (4,21)	28,35 (4,26)	-	1,748	0,417
Diabetes	47,8%^¶ ¶ ρ ≤ 0,05;	20,4%^* * Reference group(s); BMI: Body mass index; BP: Blood pressure; GFR: Glomerular filtration rate; Hx: History; CVD: Cardiovascular disease; HADS-B: Hospital Anxiety and Depression Scale domain B;	30,0%	7,728	-	0,021
Systolic BP^§ § Metric variables, represented by mean values and standard deviation between brackets.	145,0 (24,93)	139,7 (14,91)	141,6 (14,84)	-	1,581	0,454
Diastolic BP^§ § Metric variables, represented by mean values and standard deviation between brackets.	70,9 (8,90)	72,7 (8,83)	73,5 (8,81)	-	1,747	0,417
Hypertension	91,3%	85,3%	84,2%	0,784	-	0,694
c-HDL^§ § Metric variables, represented by mean values and standard deviation between brackets.	53,26 (13,76)	52,96 (11,38)	55,9 (14,81)	-	1,739	0,419
c-LDL^§ § Metric variables, represented by mean values and standard deviation between brackets.	108,10 (35,91)	121,84 (30,68)	116,20 (29,91)	-	5,150	0,076
c-Total^§ § Metric variables, represented by mean values and standard deviation between brackets.	188,6 (42,76)	200,0 (35,15)	194,9 (35,47)	-	3,000	0,223
Triglycerides^§ § Metric variables, represented by mean values and standard deviation between brackets.	132,8 (43,4)	122,4 (52,2)	114,9 (52,0)	-	5,054	0,080
Dyslipidemia	60,9%	64,1%	63,2%	0,085	-	0,980
Smoking	0%	4,9%	2,5%	1,162	-	0,556
Anemia	54,5%^¶ ¶ ρ ≤ 0,05;	8,8%^* * Reference group(s); BMI: Body mass index; BP: Blood pressure; GFR: Glomerular filtration rate; Hx: History; CVD: Cardiovascular disease; HADS-B: Hospital Anxiety and Depression Scale domain B;	5,2%^* * Reference group(s); BMI: Body mass index; BP: Blood pressure; GFR: Glomerular filtration rate; Hx: History; CVD: Cardiovascular disease; HADS-B: Hospital Anxiety and Depression Scale domain B;	30,308	-	< 0,001
Thyroid disorder	4,3%	7,8%	8,3%	0,220	-	1,000
Hx DCV	30,4%	23,3%	14,2%	5,030	-	0,085
HADS-B^§ § Metric variables, represented by mean values and standard deviation between brackets.	7,7 (4,6)	7,07 (3,8)	7,08 (4,2)	-	0,552	0,759
Cognitive function^§ § Metric variables, represented by mean values and standard deviation between brackets. ^‡ ‡ MMSE final score (not adjusted);	21,74^¶ ¶ ρ ≤ 0,05; (4,8)	24,80 (4,1)	23,88^* * Reference group(s); BMI: Body mass index; BP: Blood pressure; GFR: Glomerular filtration rate; Hx: History; CVD: Cardiovascular disease; HADS-B: Hospital Anxiety and Depression Scale domain B; (4,3)	-	10,264	0,006
Cognitive impairment^† † dichotomous variable adjusted for years of schooling.	34,8%^¶ ¶ ρ ≤ 0,05;	10,7%^* * Reference group(s); BMI: Body mass index; BP: Blood pressure; GFR: Glomerular filtration rate; Hx: History; CVD: Cardiovascular disease; HADS-B: Hospital Anxiety and Depression Scale domain B;	24,2%^¶ ¶ ρ ≤ 0,05;	8,943	-	0,010

Variáveis	DC		Pearson Chisquare/Fisher exact test	Odds Ratio (IC95%)	Kruskal - Wallis	Exact Sig. (2-sided)
	Com disfunção	Sem disfunção
Frequência absoluta	48	198	-	-	-	-
Gênero (feminino)	62,5%	50,5%	1,538	0,612 (0,320-1,170)	-	0,135
Idade§	74,67¶ (5,7)	71,64 (5,1)	-	-	11,537	0,010
Escolaridade§	3,06 (3,7)	3,19 (3,7)	-	-	0,734	0,392
IMC§	27,8 (4,6)	28,5 (4,3)	-		1,353	0,243
Diabetes	29,2%	27,2%	0,069	1,098 (0,547-2,204)	-	0,792
TA Sistólica§	141,1 (16,6)	141,1 (16,1)	-	-	< 0,001	0,985
TA Diastólica§	72,6 (8,4)	73,0 (9,0)	-	-	0,033	0,855
HTA	83,0%	85,9%	0,282	0,800 (0,351-1,824)	-	0,661
c-HDL§	54,4 (15,8)	54,4 (12,8)	-	-	0,059	0,807
c-LDL§	119,7 (33,2)	117,4 (30,6)	-	-	0,266	0,606
c-Total§	198,9 (37,0)	195,9 (35,9)	-	-	0,430	0,512
Triglicerídeos§	128,6 (53,5)	117,9 (51,5)	-	-	2,063	0,151
Dislipidemia	66,7%	62,5%	0,301	1,200 (0,626-2,302)	-	0,627
Tabagismo	0%	4,2%	-	-	-	0,208
Anemia	13,7%	10,6%	0,382	1,229 (0,466-3,242)	-	0,677
Disfunção Tireoídea	5,7%	8,3%	-	0,664 (0,186-2,369)	-	0,772
Hx DCV	18,9%	19,7%	0,894	0,949 (0,437-2,057)	-	0,148
HADS-B§	8,47¶ (4,2)	6,82 (3,97)	-	-	6,390	0,011

GFR (ml/min/1,73 m²)	B (EP)	Sig	Odds Ratio [Exp(B)]	95 CI% [Exp(B)]
GFR (ml/min/1,73 m²)	B (EP)	Sig	Odds Ratio [Exp(B)]	Lower	Upper
60,00-89,99		Reference
< 60,00	1,495 (0,542)	0,006	4,461	1,543	12,897
≥ 90,00	0,980 (0,384)	0,011	2,665	1,256	5,654

Variables	B(EP)	Sig		Odds Ratio [Exp(B)]	95% CI [Exp(B)]
	60-89			GFR reference	Lower	Upper
GFR	≤ 60	1,512 (0,659)	0,021	4,534	1,257	16,356
(ml/min/1,73 m²)
	≥ 90	1,195 (0,419)	0,005	3,302	1,434	7,607
Gender		0,398 (0,386)	0,303	1,488	0,699	3,170
Age		0,131 (0,035)	< 0,001	1,140	1,063	1,223
Years of education		0,097 (0,069)	0,140	1,107	0,967	1,266
Anemia		-0,354 (0,643)	0,583	0,702	0,198	2,486
Diabetes		-0,200 (0,415)	0,631	0,818	0,361	1,855
Hypertension		-0,641 (0,492)	0,199	0,527	0,200	1,391
HADS		0,085 (0,044)	0,050	1,091	1,000	1,190

Variable	Definition	Type	Possible values
Gender	Patient gender.	Qualitative	Female
Gender	Patient gender.	Dichotomous	Male
Age	Patient age in years at the time they answered the study questionnaire.	Quantitative	65,66,67...
Age		Discrete	65,66,67...
Education^* * Collected from study "The impact of thyroid disorders on the cognition and mood of elderly individuals: a cross-sectional study of health care system users registered with the Ponte FHU";	Number of years the patients had gone to school for at the time they answered the study questionnaire.	Quantitativa	1,2,3...
		Discreta	1,2,3...
Body mass index	Body mass index - Weight/Height2 (never prior to January 1, 2010).	Quantitative	18.1, 18,2, 18,3...
Body mass index		Continuous	18.1, 18,2, 18,3...
Treatment for Diabetes Mellitus	At least one medication from the following drug classes:	Qualitative	Yes
	Sulfonylureas
	Biguanides
	Glucosidase inhibitors
	Glitazones	Dichotomous	No
	Gliptins
	Insulin
Diabetes Mellitus	At least one of the following data:^† † Standards from the Department of Health, Diagnosis, and Classification for Diabetes Mellitus, nº 002/2011; :	Qualitative	No
	Fasting glucose ≥ 126 mg/dl;
	Occasional glucose level ≥ 200 mg/dl plus classic symptoms of diabetes (polyuria, polydipsia, polyphagia, or involuntary weight loss);
	Glucose ≥ 200 mg/dl two hours after OGTT with 75 mg of glucose;	Dichotomous	Yes
	A1C hemoglobin ≥ 6.5%;
	Treatment for Diabetes Mellitus..
	(never prior to January 1, 2010; fasting glucose and HbA1C with at least two altered values within a minimum of one week).
Systolic blood pressure	Mean value of the two systolic BP measurements taken closer to the application of the MMSE (prior to January 1, 2010).	Quantitative	100,101,102...
Systolic blood pressure		Discrete	100,101,102...
Diastolic blood pressure	Mean value of the two diastolic BP measurements taken closer to the application of the MMSE (prior to January 1, 2010).	Quantitative	50,51,52...
Diastolic blood pressure		Discrete	50,51,52...
Treatment for hypertension	At least one medication from the following drug classes:	Qualitative	No
	Angiotensin-converting-enzyme (ACE) inhibitors
	Angiotensin receptor blockers (ARB),
	Beta-1 Blockers (B1B),	Dichotomous	Yes
	Calcium channel blockers (CCB)
	Diuretics.
Hypertension	Systolic BP > 160 mmHg, Diastolic BP > 90 mmHg, or treatment for hypertension.	Quantitative	No
Hypertension		Dichotomous	Yes
Total cholesterol	Total cholesterol measurement (mg/dl) taken closer to the application of the MMSE (never prior to January 1, 2010).	Quantitative	150.0, 150.1, 150.2...
Total cholesterol		Continuous	150.0, 150.1, 150.2...
HDL cholesterol	HDL cholesterol measurement (mg/dl) taken closer to the application of the MMSE (never prior to January 1, 2010).	Quantitative	20.0, 20.1, 20.2...
HDL cholesterol		Continuous	20.0, 20.1, 20.2...
LDL cholesterol	LDL cholesterol measurement (mg/dl) taken closer to the application of the MMSE (never prior to January 1, 2010).	Quantitative	70.0, 70,1, 70,2...
LDL cholesterol		Continuous	70.0, 70,1, 70,2...
Triglycerides	Triglycerides measurement (mg/dl) taken closer to the application of the MMSE (never prior to January 1, 2010).	Quantitative	70.0, 70.1, 70.2...
Triglycerides		Continuous	70.0, 70.1, 70.2...
Dyslipidemia	At least one of the following^‡ ‡ Standards from the Department of Health, Therapeutic Approaches to Dyslipidemia, nº 019/2011; :
	Total cholesterol > 190 mg/dl;
	HDL cholesterol < 40 mg/dl of male or < 45 mg/dl if female;;	Qualitative	No
	LDL cholesterol > 115 mg/dl;	Dichotomous	Yes
	iglycerides > 150 mg/dl.
Smoking	Past or recent active smoking	Qualitative	No
Smoking	Past or recent active smoking	Dichotomous	Yes
Anemia	Hemoglobin < 13 g/dl or hematocrit < 39%, if male; hemoglobin < 12 g/dl or hematocrit < 37%, if female; or ICPC-2 classification for anemia (B78, B80, B81 or B82).	Qualitative	No
Anemia		Dichotomous	Yes
Thyroid disorder 1	TSH levels off the 0.27-4.20 μIU/ml range or free T4 of the 0.93-1.70 ng/dl range.	Qualitative	No
Thyroid disorder 1		Dichotomous	Yes
History of cardiovascular disease	History of the following conditions, as defined in the ICPC-2:
	K74 Ischemic heart disease with angina;
	K75 Acute myocardial infarction
	K76 K76 Ischemic heart disease without angina
	K77 Heart failure	Qualitative	No
	K78 Atrial fibrillationr	Dichotomous	Yes
	K80 Cardiac arrhythmia
	K89 Transient cerebral ischemia
	K90 Stroke/cerebrovascular accident
	K91 Cerebrovascular disease
HADS-B1	Score on HADS-B.	Quantitative	1,2,3...
HADS-B1	Score on HADS-B.	Discrete	1,2,3...
Cognitive function 1	Final MMSE score.	Quantitative	0,1...30.
Cognitive function 1	Final MMSE score.	Discrete	0,1...30.
Cognitive impairment	MMSE score:
	≤ 15, if years of education = 0 years;	Qualitative	No
	≤ 22, if years of education between 1 and 11 years;	Dichotomous	Yes
	≤ 27, if years of education > 11 years.
Creatinine	Creatinine level measurement (mg/dl) taken closer to the application of the MMSE (never prior to January 1, 2010).	Quantitative	0.50, 0.51, 0.52...
Creatinine		Continuous	0.50, 0.51, 0.52...
Glomerular filtration rate	GFR calculated using the MRDR equation ^§ § Equation from the Modification of Diet in Renal Disease (MDRD) study: GFR = 186.3 x serum creatinine -1.154 x age-0.203 x 1.212 if of African descent x 0.742 if female. .	Quantitative	70.1, 70.2, 70.3...
Glomerular filtration rate		Continuous	70.1, 70.2, 70.3...
Glomerular filtration rate groups	Groups of patients with different glomerular filtration rate ranges		TFG ≤ 60
		Qualitative	60
		Ordinal	TFG ≥ 90
			(ml/min/1,73 m²)

Variável	Definição	Tipo	Valores a assumir
Género	Sexo a que pertence o utente.	Qualitativa	Feminino
Género	Sexo a que pertence o utente.	Dicotômica	Masculino
Idade	Número de anos completos à data da aplicação do questionário.	Quantitativa	65,66,67...
Idade		Discreta	65,66,67...
Escolaridade^* * Recolhidas do estudo "A Influência da disfunção tiroideia na cognição e estado de humor do idoso: estudo transversal de utentes inscritos na USF-Ponte";	Número de anos completos de estudo, à data de realização do questionário.	Quantitativa	1,2,3...
		Discreta	1,2,3...
Índice de Massa Corporal	Valor do índice de massa corporal ou valor do Peso/Altura² (nunca anterior a 01/01/2010).	Quantitativa	18.1, 18,2, 18,3...
Índice de Massa Corporal		Contínua	18.1, 18,2, 18,3...
Tratamento para Diabetes Mellitus	Pelo menos um fármaco das seguintes classes:	Qualitativa	Sim
	Sulfonilureias
	Biguanidas
	Inibidores da glicosidase
	Glitazonas	Dicotômica	Não
	Gliptinas
	Insulina
Diabetes Mellitus	Pelo menos um destes registros^† † Norma da Direção Geral da Saúde, Diagnóstico e Classificação da Diabetes Mellitus, nº 002/2011; :	Qualitativa	Não
	Glicemia em jejum ≥ 126 mg/dl;
	Glicemia ocasional ≥ 200 mg/dl mais Sintomas Clássicos de Diabetes (poliúria, polidipsia, polifagia ou perda involuntária de peso);
	Glicemia ≥ 200 mg/dl às 2 horas na PTOG com 75 mg de glicose;	Dicotômica	Sim
	Hemoglobina A1C ≥ 6.5%;
	Tratamento para Diabetes Mellitus.
	(nunca anterior a 01/01/2010; nos casos da glicemia em jejum e HbA1C, deverão existir pelo menos dois valores alterados, separados num mínimo de uma semana).
Tensão Arterial Sistólica	Média das duas medições de tensão arterial sistólica mais próximas da data da aplicação do MMSE (anteriores a 01/01/2010).	Quantitativa	100,101,102...
Tensão Arterial Sistólica		Discreta	100,101,102...
Tensão Arterial Diastólica	Média das duas medições de tensão arterial diastólica mais próximas da data da aplicação do MMSE (anteriores a 01/01/2010).	Quantitativa	50,51,52...
Tensão Arterial Diastólica		Discreta	50,51,52...
Tratamento para Hipertensão Arterial	Pelo menos um fármaco das seguintes classes:	Qualitativa	Não
	Inibidores da Enzima de Conversão da Angiotensina (IECAs),
	Antagonistas dos Receptores da Angiotensina (ARA's),
	Bloqueadores dos Receptores B1 (BRB1),	Dicotômica	Sim
	Bloqueadores dos Receptores dos Canais de Cálcio (BRCC),
	Diuréticos.
Hipertensão Arterial	Valores de Tensão Arterial Sistólica > 160 mmHg, lensão Arterial Diastólica > 90 mmHg, ou Tratamento para Hipertensão Arterial.	Qualitativa	Não
Hipertensão Arterial		Dicotômica	Sim
Colesterol total	Valor, em mg/dl, de colesterol total, correspondente ao registro mais próximo da data da aplicação do MMSE (nunca anterior a 01/01/2010).	Quantitativa	150.0, 150.1, 150.2...
Colesterol total		Contínua	150.0, 150.1, 150.2...
Colesterol HDL	Valor, em mg/dl, de colesterol HDL, correspondente ao registro mais próximo da data da aplicação do MMSE (nunca anterior a 01/01/2010).	Quantitativa	20.0, 20.1, 20.2...
Colesterol HDL		Contínua	20.0, 20.1, 20.2...
Colesterol LDL	Valor, em mg/dl, de colesterol LDL, correspondente ao registro mais próximo da data da aplicação do MMSE (nunca anterior a 01/01/2010).	Quantitativa	70.0, 70,1, 70,2...
Colesterol LDL		Contínua	70.0, 70,1, 70,2...
Triglicerídeos	Valor, em mg/dl, de triglicerídeos, correspondente ao registro mais próximo da data da aplicação do MMSE(nunca anterior a 01/01/2010)..	Quantitativa	70.0, 70.1, 70.2...
Triglicerídeos		Contínua	70.0, 70.1, 70.2...
Dislipidemia	Pelo menos um destes registros^‡ ‡ Norma da Direção Geral da Saúde, Abordagem terapêutica das dislipidemias, nº 019/2011; :
	Colesterol Total > 190 mg/dl;
	Colesterol HD < 40 mg/dl se homem ou < 45 mg/dl, se mulher;	Qualitativa	Não
	Colesterol LDL > 115 mg/dl;	Dicotômica	Sim
	Triglicerídeos > 150 mg/dl.
Tabagismo	Tabagismo ativo passado ou recente.	Qualitativa	Não
Tabagismo	Tabagismo ativo passado ou recente.	Dicotômica	Sim
Anemia	Valores de hemoglobina < 13 g/dl ou Hematócrito < 39%, se homem; ou Hemoglobina < 12 g/dl ou Hematócrito < 37%, se mulher; ou classificação, pelo ICPC2, de anemia (B78, B80, B81 ou B82).	Qualitativa	Não
Anemia		Dicotômica	Sim
Disfunção Tiroideia¹	Existência de valores de TSH fora do intervalo 0,274,20 MIU/ml ou de T4 livre fora do intervalo 0,93-1.70 ng/dl.	Qualitativa	Não
Disfunção Tiroideia¹		Dicotômica	Sim
História de Doença Cardiovascular	Existência de história de alguma das seguintes patologias, definidas por meio do ICPC2:
	K74 Doença cardíaca isquêmica com angina;
	K75 Enfarte Agudo do Miocárdio
	K76 Doença cardíaca isquêmica sem angina
	K77 Insuficiência Cardíaca	Qualitativa	Não
	K78 Fibrilação Auricular	Dicotômica	Sim
	K80 Arritmia cardíaca NE
	K89 Isquemia cerebral transitória
	K90 Trombose/Acidente Vascular Cerebral
	K91 Doença Vascular Cerebral
HADS-B1	Pontuação obtida por meio do HADS-B.	Quantitativa	1,2,3...
HADS-B1	Pontuação obtida por meio do HADS-B.	Discreta	1,2,3...
Função cognitiva¹	Pontuação final do MMSE.	Quantitativa	0,1...30.
Função cognitiva¹	Pontuação final do MMSE.	Discreta	0,1...30.
Disfunção Cognitiva	Pontuação no MMSE:
	≤ 15, se escolaridade de 0 anos;	Qualitativa	Não
	≤ 22, se escolaridade entre 1 e 11 anos;	Dicotômica	Sim
	≤ 27, se escolaridade superior 11 anos.
Creatinina	Valor, em mg/dl, de creatinina, correspondente ao registro mais próximo da data da aplicação do MMSE (nunca anterior a 01/01/2010).	Quantitativa	0.50, 0.51, 0.52...
Creatinina		Contínua	0.50, 0.51, 0.52...
Taxa de Filtração Glomerular	Valor calculado por meio da fórmula da MDRD^§ § Equação do estudo Modification of Diet in Renal Disease (MDRD): TFG = 186,3 x Creatinina sérica-1,154 x idade-0.203 x 1,212 se raça negra x 0,742 se gênero feminino. .	Quantitativa	70.1, 70.2, 70.3...
Taxa de Filtração Glomerular		Contínua	70.1, 70.2, 70.3...
Categorias da Taxa de Filtração Glomerular	Categoria em que se enquadra o valor da Taxa de Filtração Glomerular		TFG ≤ 60
		Qualitativa	60
		Ordinal	TFG ≥ 90
			(ml/min/1,73 m²)

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[1] Correspondence to: João Pedro Vieira Antunes. Brás-Oleiro Family Health Unit, Porto Health Care Center Group II, Gondomar, Portugal. Rua Professor Machado Vilela, nº 285, Braga, Portugal. CEP: 4715-045. E-mail: joaopeantunes@gmail.com