Demographics and clinical features of elderly patients undergoing regular dialysis in Brazil

An increasing number of elderly people in renal support is expected in the coming years. The objective of this study was to report the clinical and socio-demographic data of end-stage renal disease (ESRD) adult patients undergoing regular dialysis treatment comparing elderly (≥65 years old) and non-elderly subjects using data from the Brazilian Dialysis Registry database. The regional distribution of the sample was Southeast (48.8%), South (33.7), Northeast (13.1%), Midwest (5.1%), and North (0.1%). A total of 18,030 patients were included in the analysis with elderly patients accounting for 29.5% of the sample. The elderly patients were predominantly male, white, retired, and literate. Elderly ESRD patients had a slightly higher frequency of undernourishment and a lower frequency of obesity than the non-elderly adults. A higher frequency of elderly patients were from the South and Southeast regions. The dialysis treatment of patients from both groups was predominantly funded by the public system, but the percent of non-public funding was higher for the elderly group. The most used initial access in the elderly was the central venous catheter and hemodialysis was the main modality at the beginning of treatment (93.2%), as well as during maintenance therapy (91.8%). Advanced age was associated with greater use of central venous catheter in the first dialysis session. The survival of the elderly on dialysis was lower than that of the non-elderly early in the course of dialysis and this difference increased over time. This is yet the largest national epidemiological study of elderly people on chronic dialysis.

Does soy increase blood counts in myelodysplastic syndromes? / Será que a soja aumenta as contagens sanguíneas em síndrome mielodisplásica?

Myelodysplastic syndromes (MDS) are a group of clonal stem cell diseases characterized by ineffective hematopoiesis, bone marrow hyperproliferation, cytopenias in peripheral blood and risk of transformation into acute leukemia. We decided to investigate the effects of a soy concentrate on MDS patients based on the follow-up results of a 61 year-old Japanese female patient who was diagnosed with MDS and refractory cytopenia with multilineage dysplasia in 2003 (hemoglobin = 11g/dL; white blood cells count = 2,500/uL and platelets = 25,000/uL; marrow with mild dysplasia and normal karyotype; paroxysmal nocturnal hemoglobinuria was excluded). She started using soy as a dietary supplementation in May 2004 and presented a gradual increment in blood counts, achieving normalization approximately eight months afterwards. Among the soy components, the main compounds with anti-carcinogenic activity are the isoflavones (genistein and daidzein). Based on these lines of evidence, we proposed to administer daily a standard soy concentrate to 14 MDS out-patients for a minimum period of three months and maximum of 12 months, in an attempt to evaluate prospectively the possible increase in hemoglobin, neutrophils and platelet counts. A historical control group was used to compare results. The use of a soy concentrate in a standardized manner was associated with an increase in neutrophil and/or platelet counts in some cases, but spontaneous increments were also observed in historical controls. This preliminary study does not allow establishing a relation between soy supplementation and blood cell count increase.

As síndromes mielodisplásicas (SMD) são um grupo das doenças clonais de células-tronco caracterizado por hematopoese ineficaz, hiperproliferação de medula óssea, citopenias no sangue periférico e risco de transformação para leucemia aguda. Decidimos investigar os efeitos de um concentrado de soja em pacientes com SMD com base no fato de termos o seguimento de uma paciente japonesa, de 61 anos de idade, que foi diagnosticada em 2003 com SMD, citopenia refratária com displasia subtipo multilinhagens (hemoglobina = 11 g/dL; contagem de glóbulos brancos = 2.500/uL e plaquetas = 25.000/uL; medula com displasia leve e cariótipo normal; hemoglobinúria paroxística excluída), e que começou a usar a soja como suplemento alimentar em maio de 2004, apresentando gradual aumento da contagem das células sanguíneas, atingindo a normalização cerca de oito meses depois. Entre os componentes da soja, os principais compostos com propriedades anticarcinogênese são as isoflavonas (Ge nisteína e daidzeína). Com base nessas linhas de evidência, foi proposto oferecer diariamente um concentrado de soja padrão, por um período mínimo de três meses e máximo de doze meses, a 14 pacientes ambulatoriais, na tentativa de avaliar, prospectivamente, o possível aumento de hemoglobina, neutrófilos e plaquetas. Um grupo controle histórico foi utilizado para comparar os resultados. O uso de um concentrado de soja de forma padronizada foi associado ao aumento na contagem de neutrófilos e/ou de plaquetas em alguns casos, mas aumentos espontâneos também foram observados em controles históricos. Este estudo preliminar não permite estabelecer relação entre o uso de soja e o aumento na contagem sanguínea.

Cross-transmission of vancomycin-resistant Enterococcus in patients undergoing dialysis and kidney transplant

The objective of this study was to investigate the occurrence of vancomycin-resistant Enterococcus (VRE) cross-transmission between two patient groups (long-term dialysis and kidney transplant patients). Molecular typing, by automated ribotyping with the RiboPrinter Microbial Characterization System (Qualicon, USA), was used to analyze VRE isolates from 31 fecal samples of 320 dialysis patients and 38 fecal samples of 280 kidney transplant patients. Clonal spread of E. faecalis and E. casseliflavus was observed intragroup, but not between the two groups of patients. In turn, transmission of E. gallinarum and E. faecium between the groups was suggested by the finding of vancomycin-resistant isolates belonging to the same ribogroup in both dialysis and transplant patients. The fact that these patients were colonized by VRE from the same ribogroup in the same health care facility provides evidence for cross-transmission and supports the adoption of stringent infection control measures to prevent dissemination of these bacteria.

Cystatin C and renal function in pediatric kidney transplant recipients

In clinical practice, the glomerular filtration rate (GFR) is often determined with serum creatinine. However, studies have shown cystatin C to be a better parameter for the diagnosis of impaired renal function. We compared GFR estimated by plasma cystatin C with GFR estimated by serum creatinine in a sample of 50 pediatric renal transplant recipients and 24 healthy children. The correlation between GFR estimated by serum creatinine and by cystatin C was significant (r = 0.75; P < 0.001, Person’s correlation); however, in pediatric kidney transplant recipients, the GFR was 6.7 mL/min lower when determined using cystatin C rather than serum creatinine. Moreover, using GFR estimated by cystatin C we found that 42 percent of the pediatric kidney transplant recipients had an estimated GFR <60 mL·min-1·1.73 (m²)-1, whereas when GFR was estimated by the serum creatinine formula only 16 percent of the children had values below this cutoff point indicative of chronic kidney disease (P < 0.001). We conclude that, in pediatric kidney transplant recipients, estimation of GFR yields lower values when cystatin C is used rather than serum creatinine.

Association of urinary 90 kDa angiotensin- converting enzyme with family history of hypertension and endothelial function in normotensive individuals

We described angiotensin-I-converting enzyme (ACE) isoforms with molecular masses of 190, 90, and 65 kDa in the urine of normotensive offspring of hypertensive subjects. Since they did not appear in equal amounts, we suggested that 90 kDa ACE might be a marker for hypertension. We evaluated the endothelial response in normotensive offspring with or without family history of hypertension and its association with the 90 kDa ACE in urine. Thirty-five normotensive subjects with a known family history of hypertension and 20 subjects without a family history of hypertension, matched for age, sex, body weight, and blood pressure, were included in the study. Endothelial function was assessed by ultrasound and a sample of urine was collected for determination of ACE isoforms. In the presence of a family history of hypertension and detection of 90 kDa ACE, we noted a maximal flow mediated dilation of 12.1 ± 5.0 vs 16.1 ± 6.0 percent in those without a previous history of hypertension and lacking urinary 90 kDa ACE (P < 0.05). In subjects with a family history of hypertension and presenting 90 kDa ACE, there were lower levels of HDL-cholesterol (P < 0.05) and higher levels of triglycerides (P < 0.05). Subjects with 90 kDa ACE irrespective of hypertensive history presented a trend for higher levels of triglycerides and HDL-cholesterol (P = 0.06) compared to subjects without 90 kDa ACE. Our data suggest that the 90 kDa ACE may be a marker for hypertension which may be related to the development of early atherosclerotic changes.

Cultural adaptation and validation of the "Kidney Disease and Quality of Life - Short Form (KDQOL-SFÕ 1.3)" in Brazil

The objective of the present study was to translate the Kidney Disease Quality of Life - Short Form (KDQOL-SFÕ1.3) questionnaire into Portuguese to adapt it culturally and validate it for the Brazilian population. The KDQOL-SF was translated into Portuguese and back-translated twice into English. Patient difficulties in understanding the questionnaire were evaluated by a panel of experts and solved. Measurement properties such as reliability and validity were determined by applying the questionnaire to 94 end-stage renal disease patients on chronic dialysis. The Nottingham Health Profile Questionnaire, the Karnofsky Performance Scale and the Kidney Disease Questionnaire were administered to test validity. Some activities included in the original instrument were considered to be incompatible with the activities usually performed by the Brazilian population and were replaced. The mean scores for the 19 components of the KDQOL-SF questionnaire in Portuguese ranged from 22 to 91. The components "Social support" and "Dialysis staff encouragement" had the highest scores (86.7 and 90.8, respectively). The test-retest reliability and the inter-observer reliability of the instrument were evaluated by the intraclass correlation coefficient. The coefficients for both reliability tests were statistically significant for all scales of the KDQOL-SF (P < 0.001), ranging from 0.492 to 0.936 for test-retest reliability and from 0.337 to 0.994 for inter-observer reliability. The Cronbach's alpha coefficient was higher than 0.80 for most of components. The Portuguese version of the KDQOL-SF questionnaire proved to be valid and reliable for the evaluation of quality of life of Brazilian patients with end-stage renal disease on chronic dialysis.

Renal dysfunction in patients with sickle cell anemia or sickle cell trait

Patients with sickle cell anemia (Hb SS) or sickle cell trait (Hb AS) may present several types of renal dysfunction; however, comparison of the prevalence of these abnormalities between these two groups and correlation with the duration of disease in a large number of patients have not been thoroughly investigated. In a cross-sectional study using immunoenzymometric assays to measure tubular proteinuria, microalbuminuria, measurement of creatinine clearance, urinary osmolality and analysis of urine sediment, we evaluated glomerular and tubular renal function in 106 adults and children with Hb SS (N = 66) or Hb AS (N = 40) with no renal failure (glomerular filtration rate (GFR)>85 ml/min). The percentage of individuals with microalbuminuria was higher among Hb SS than among Hb AS patients (30 vs 8 per cent, P<0.0001). The prevalence of microhematuria was similar in both groups (26 vs 30 per cent, respectively). Increased urinary levels of retinol-binding protein or ß2-microglobulin were detected in only 3 Hb SS and 2 Hb AS patients. Urinary osmolality was reduced in patients with Hb SS or with Hb AS; however, it was particularly evident in Hb SS patients older than 15 years (median = 393 mOsm/kg, range = 366-469) compared with Hb AS patients (median = 541 mOsm/kg, range = 406-722). Thus, in addition to the frequently reported early reduction of urinary osmolality and increased GFR, nondysmorphic hematuria was found in 26 and 30 per cent of patients with Hb SS or Hb AS, respectively. Microalbuminuria is an important marker of glomerular injury in patients with Hb SS and may also be demonstrated in some Hb AS individuals. Significant proximal tubular dysfunction is not a common feature in Hb SS and Hb AS population at this stage of the disease (i.e., GFR>85 ml/min)

Idiopathic focal segmental glomerulosclerosis and HLA antigens

The objective of the present study was to investigate a possible association between HLA class II antigens and idiopathic focal segmental glomerulosclerosis (FSGS), HLA-A, -B, -DR and -DQ antigens were determined in 19 Brazilian patients (16 white subjects and three subjects of Japanese origin) with biopsy-proven FSGS. Comparison of the HLA antigen frequencies between white patients and white local controls showed a significant increase in HLA-DR4 frequency among FSGS patients (37.7 vs 17.2 percent, P<0.05). In addition, the three patients of Japanase extraction, not included in the statistical analysis, also presented HLA-DR4. In conclusion, our data confirm the association of FSGS with HLA-DR4 previously reported by others, thus providing further evidence for a role of genes of the HLA complex in the susceptibility to this disease.

Late diagnosis of chronic renal failure

A comparison was made between patients with a late diagnosis chronic renal failure (1 month or less before starting dialysis, N = 9 and those with an early diagnosis (6 months or more, N = 45) in terms to of the following aspects: referral characteristics during the pre-dialysis phase, demographic details and patient biochemistry prior to maintenance dialysis. Information was obtained by surveying consecutive patients with primary renal disease admitted to a university dialysis unit in Sao Paulo. Fifty-three percent of all patients surveyed had a late diagnosis. These patients had a lower median duration of symptoms (2 vs 6 months, P<0.01) and were less likely to be referred for dialysis by a nephrologist (9 per cent vs 51 per cent, P<0.001) than early diagnosis patients. In the early diagnosis group, 7 patients (16 per cent) had follow-up care for less than 6 months and 11 (24 per cent) did not receive any follow-up; 21 patients (47 per cent) did not follow a low-protein diet. At the start of dialysis, patients with a late diagnosis had higher blood pressure and a higher rate of pulmonary infections (19 per cent vs 4 per cent, P= 0.03). Mean concentrations of BUN, serum creatinine and potassium were significantly higher and mean blood bematocrit was lower for the late diagnosis group. After 3 months of dialysis, the mortality rate was higher in the late than in the early diagnosis group (22.9 per cent vs 6.7 per cent, = 0.02). Late diagnosis of chronic renal failure and lack of adequate follow-up care, prior to the start of dialysis, are common. Interventions to promote early diagnosis of chronic renal failure and to improve compliance with regular nephrological follow-up can be important to reduce the morbidity and the mortality of patients with chronic renal insufficiency.

Late diagnosis of chronic renal failure and the quality of life during dialysis treatment

We evaluated the quality of life of 101 hemodialysis patients who had a late (( 3 months before starting dialysis, N=47) or early (( 6 months), N= 54) diagnosis of chronic renal failure. At the time of the survey patients had been stable on dialysis for at least 3 months and for less than 24 months; median duration of dialysis was 9.1 months. Quality of life was measured by the kidney disease questionnaire (including the intensity and duration of physical symptoms, fatigue, depression, relationship with others and frustation), the health and life satisfaction indices, functional status (Karnofsky scale), and the time trade-off method. Scores for the several indicators of quality of life were closely similar for the late and early diagnosis groups. Health satisfaction compared to one year prior to dialysis was slighly better for the early diagnosis group. For both groups, functional status was a little worse during the first year of dialysis than one year before its start. In the late diagnosis group, elderly patients and diabetics had more impairment in several dimensions assessed. In addition, in this group greater income was significantly correlated with better physical performance (r = 0.52, P<0.001) and with health satisfaction (r = 0.36, P= 0.027). These findings suggest that after a median duration of 9 months on a dialysis program, patients with a late and early diagnosis of chronic renal failure have a similar performance in terms of quality of life parameters. Age, diabetes and income are associated with the quality of life of pataients with a late diagnosis.

Acesso ao tratamento dialítico crônico: deficiente e desigual / Access to chronic dialysis treatment: deficient and unequal

OBJETIVO. Determinar a fraçao de pacientes com insuficiência renal crônica (IRCT) tratada por meio de diálise no Município de Sao Paulo e investigar a influência da idade em relaçao ao acesso a diálise. MATERIAL E MÉTODOS. Foram estudados todos os pacientes que receberam diálise para IRCT durante o ano de 1991, registrados junto à Secretaria de Saúde do Estado. No mesmo ano, foram também coletadas informaçoes dos indivíduos que morreram tendo com causa básica de óbito doença relacionada a insuficiência renal crônica. Estes últimos dados foram obtidos do Serviço Funerário da Prefeitura de Sao Paulo. Cruzando-se os dados destes bancos de dados foi possível descobrir os pacientes que morreram de IRCT sem ter realizado diálise e calcular a fraçao tratada nas diversas faixas etárias. RESULTADOS. De forma global, 25,6 por cento dos pacientes com IRCT nao receberam tratamento. A partir da idade de 40 anos, houve reduçao progressiva e significante (p<0,001) da fraçao de pacientes tratados conforme aumentou a idade. Até os nove anos de idade a percentagem de tratamento também foi reduzida (29 por cento). Indivíduos nas faixas etárias de 60-69 e 70-79 anos apresentaram chance cerca de 5 e 11 vezes maior, respectivamente, de morrer sem receber tratamento dialítico do que aqueles no grupo etário de 20-29 anos. CONCLUSOES. Os autores estimam que pelo menos um quarto dos pacientes com IRCT morreram em Sao Paulo, em 1991, sem ter recebido tratamento dialítico. Idade é um fator importante de discriminaçao para aceitaçao em programas de diálise crônica.

Sobrevida de pacientes diabéticos em diálise / Survival of diabetic patients in dialysis

OBJETIVO. Diabetes melito é uma causa de insuficiência renal terminal de importância crescente. Nosso objetivo foi avaliar a sobrevida depacientes diabéticos e näo-diabéticos em tratamento dialítico. MATERIAL E MÉTODOS. Foram estudados 295 pacientes em programa de diálise em um centro de referência terciário na cidade de Säo Paulo, entre 1992 e 1994. Setenta e um paciente eram diabéticos (17 do tipo I e 54 do tipo II) e 224 tinham outros diagnósticos dedoença de base. Os dados foram coletados prospectivamente através de formuláriospadronizados, e também retrospectivamente, para pacientes que iniciaram tratamento entre 1992 e junho 1993. Análise de sobrevida foi realizada por meio do método do produto limite. RESULTADOS. Os pacientes diabéticos apresentavam média de idade mais elevada e uma maior proporçäo utilizava diálise peritoneal em relaçäo aos näo-diabéticos. Após um ano, a taxa de sobrevida foi 67 por cento e 86 por cento para pacientes diabéticos e näo-diabéticos (p<0,0001). A diferença de sobrevida se acentuou com a duraçäo do tratamento. Esta diferença foi observada tantoem pacientes mais jovens (ó50 anos) quanto nos mais idosos, embora tenha sido mais precoce nos primeiros. A sobrevida dos diabéticos permaneceu significantemente reduzida, ajustando-se para a idade dos pacientes. CONCLUSÖES. Pacientes diabéticos em diálise apresentam taxa de sobrevida inferior aos näo-diabéticos, independentemente da sua idade média mais elevada. Cuidados especiais devem ser dedicados a estes pacientes, tanto em relaçäo a fatores co-mórbidos pré-diálise quanto durante o tratamento dialítico, a fim de se melhorar a sua sobrevida.

Aspectos epidemiológicos do tratamento dialítico na Grande Säo Paulo / Epidemiologic aspects of the dialysis treatment in Great Säo Paulo

OBJETIVO: Apresentar dados epidemiológicos sobre o tratamento de pacientes com insuficiência renal terminal na Grande Säo Paulo. MATERIAL E MÉTODOS: Pacientes em diálise na Grande Säo Paulo distribuídos em 15 Escritórios Regionais de Saúde (ERSAs), durante o ano de 1991. Dados coletados pela Secretaria de Saúde do Estado. RESULTADOS: Houve aumento de 18,6 por cento no número de pacientes vivos em diálise de 1/janeiro a 31/dezembro (n=2.425 a 2.875). Os pacientes estavam distribuídos em 40 centros de diálise, dos quais 25 estavam localizados apenas nos ERSAs 1,2 e 3. Dependendo do ERSA, uma percentagem variável de 37 por cento a 88 por cento dos pacientes näo residiam na regiäo de tratamento. Ao final do ano, 79 por cento dos pacientes estavam em hemodiálise, 15 por cento em diálise ambulatorial peritoneal contínua e 6 por cento em diálise peritoneal intermitente. Os diagnósticos mais freqüentemente reportados de doença de base foram: indeterminado, glomerulonefrite, hipertensäo e diabetes (36 por cento, 27 por cento, 17 por cento e 8 por cento, respectivamente). Iniciaram tratamento dialítico durante o ano, 1.483 casos novos, correspondendo à incidência de 83 pacientes por milhäo da populaçäo (PMP). A prevalência de pacientes em tratamento dialítico no meio do ano foi de 148 pmp. A taxa de fatalidade anual global foi de 17,2 pacientes em cada 100 pacientes em diálise (variaç o nos ERSAs: 12,0-32,5). A sobrevida atuarial dos pacientes que iniciaram tratamento em 1991 foi de 80,2 por cento ao final do primeiro ano. Receberam transplante renal 246 pacientes, correspondendo à taxa de 14 transplantes por milhäo da populaçäo. CONCLUSOES: Em geral, a assistência prestada através de tratamento dialítico na Grande Säo Paulo é satisfatória. Há desigualdades em relaçäo à assistência nos diferentes ERSAs e que devem refletir na distribuiçäo de hospitais de atendimento terciário na regiäo.

Renal disease in the elderly: etiology and evolution of 24 cases

We retrospectively analyzed the histological data, clinical presentations, and outcome of 24 patients aged 60 years or older at the initial evaluation for renal disease. The study setting was a referral-based nephrology clinic at a tertiary care center. Twenty-three out of the 24 patients had a mean follow-up of 16 months (range 3-48). Their mean age was 65 years (range 60-75). The most common histological diagnoses were crescentic glomerulonephritis (GN) (n = 4), membranoproliferative GN (n = 4), diffuse endocapillary proliferative GN (n = 3), and minimal change (n = 3). Clinical presentation included renal insufficiency in 16 patients, the nephrotic syndrome in 8 patients (associated in 4 with decreased renal function), and hematuria with subnephrotic rang proteinuria in 4 cases. Ten out of the 23 patients developed end-stage renal disease (ESRD). Median serum creatinine at presentation in the group that developed ESRD was significantly higher than in the group that did not develop ESRD (490 vs 270 mumol/l; p < 0.05). Seven patients died, 5 of whom had developed ESRD. A variety of renal diseases affect the kidneys of the elderly; prognosis was unfavorable in about half of the patients in this series. Larger prospective studies are needed to clarify the natural history of GN in the elderly.

Exposure to hydrocarbons and rapidly progressive glomerulonephritis

1. A case-control study of the relationship between the regular exposure to hydrocarbons and rapidly progressive glomerulonephritis (GN) was carried out in Säo Paulo, Brazil. Regular exposure was defined as 1 h or more weekly for 3 consecutive months or longer. We studied 17 patients with rapidly progressive renal failure and biopsy-proven crescentic GN and 34 matched hospital controls. 2. We found an incrased risk of rapidly progressive GN associated with exposure to organic solvents (relative risk = 5.00; 95% confidence interval = 1.14 to 22.00). The frequency of exposure to solvents was 52.9% among the patients and 17.7% among the control subjects (P < 0.05). However, no statically significant increased risk was detected in those patients who had been exposed to fuels (relative risk = 3.25; 95% confidence interval = 0.76 to 13.89); the proportion of exposure to fuels was 47.1% among the patients and 20.6% among the control subjects. 3. Renal histologic findings suggest that immune complex mediated injury as well as a direct glomerular toxic effect may participate in the pathogenesis of rapidly progressive GN associated with hydrocarbon exposure

Level of fetal hemoglobin as an indicator of clinical complications in sickle cell anemia

The fetal hemoglobin (HbF) level was used as an indicator of the development of severe clinical complications in 89 patients with sickle cell anemia (SCA). HbF was determined by the alkali denaturation technique. The mean HbF level was 6.7 + or - 4.2% (range, 0.7 to 19.2%) of total hemoglobin. Major organ failures were considered to be teerminal events of morbidity and included 8 cerebrovascular accidents, 13 aseptic necroses of the femoral head and 17 leg ulcer episodes. The characteristics of the test, including sensitivity, specificity and positive predictive value were analyzed for different levels of HbF. The overall specificities were 76,76, and 85% for HbF levels >=8,10 and 12%, respectively. The sensitivity of the test was low. The positive predictive value reached 71% for children with HbF >=8%. The data suggest that HbF level may be a useful indicator of the possibility of a patient developing serious clinical complications