COVID-19 Computed tomography patterns in renal replacement therapy patients / Padrões de tomografia computadorizada da COVID-19 em pacientes em terapia renal substitutiva

ABSTRACT Introduction: Lung diseases are common in patients with end stage kidney disease (ESKD), making differential diagnosis with COVID-19 a challenge. This study describes pulmonary chest tomography (CT) findings in hospitalized ESKD patients on renal replacement therapy (RRT) with clinical suspicion of COVID-19. Methods: ESKD individuals referred to emergency department older than 18 years with clinical suspicion of COVID-19 were recruited. Epidemiological baseline clinical information was extracted from electronic health records. Pulmonary CT was classified as typical, indeterminate, atypical or negative. We then compared the CT findings of positive and negative COVID-19 patients. Results: We recruited 109 patients (62.3% COVID-19-positive) between March and December 2020, mean age 60 ± 12.5 years, 43% female. The most common etiology of ESKD was diabetes. Median time on dialysis was 36 months, interquartile range = 12-84. The most common pulmonary lesion on CT was ground glass opacities. Typical CT pattern was more common in COVID-19 patients (40 (61%) vs 0 (0%) in non-COVID-19 patients, p < 0.001). Sensitivity was 60.61% (40/66) and specificity was 100% (40/40). Positive predictive value and negative predictive value were 100% and 62.3%, respectively. Atypical CT pattern was more frequent in COVID-19-negative patients (9 (14%) vs 24 (56%) in COVID-19-positive, p < 0.001), while the indeterminate pattern was similar in both groups (13 (20%) vs 6 (14%), p = 0.606), and negative pattern was more common in COVID-19-negative patients (4 (6%) vs 12 (28%), p = 0.002). Conclusions: In hospitalized ESKD patients on RRT, atypical chest CT pattern cannot adequately rule out the diagnosis of COVID-19.

RESUMO Introdução: Doenças pulmonares são comuns em pacientes com doença renal em estágio terminal (DRET), dificultando o diagnóstico diferencial com COVID-19. Este estudo descreve achados de tomografia computadorizada de tórax (TC) em pacientes com DRET em terapia renal substitutiva (TRS) hospitalizados com suspeita de COVID-19. Métodos: Indivíduos maiores de 18 anos com DRET, encaminhados ao pronto-socorro com suspeita de COVID-19 foram incluídos. Dados clínicos e epidemiológicos foram extraídos de registros eletrônicos de saúde. A TC foi classificada como típica, indeterminada, atípica, negativa. Comparamos achados tomográficos de pacientes com COVID-19 positivos e negativos. Resultados: Recrutamos 109 pacientes (62,3% COVID-19-positivos) entre março e dezembro de 2020, idade média de 60 ± 12,5 anos, 43% mulheres. A etiologia mais comum da DRET foi diabetes. Tempo médio em diálise foi 36 meses, intervalo interquartil = 12-84. A lesão pulmonar mais comum foi opacidades em vidro fosco. O padrão típico de TC foi mais comum em pacientes com COVID-19 (40 (61%) vs. 0 (0%) em pacientes sem COVID-19, p < 0,001). Sensibilidade 60,61% (40/66), especificidade 100% (40/40). Valores preditivos positivos e negativos foram 100% e 62,3%, respectivamente. Padrão atípico de TC foi mais frequente em pacientes COVID-19-negativos (9 (14%) vs. 24 (56%) em COVID-19-positivos, p < 0,001), enquanto padrão indeterminado foi semelhante em ambos os grupos (13 (20%) vs. 6 (14%), p = 0,606), e padrão negativo foi mais comum em pacientes COVID-19-negativos (4 (6%) vs. 12 (28%), p = 0,002). Conclusões: Em pacientes com DRET em TRS hospitalizados, um padrão atípico de TC de tórax não pode excluir adequadamente o diagnóstico de COVID-19.

Financial toxicity and dialysis: Autonomy and truth-telling in resource-limited settings

From an ethical perspective, resource limitations provide a challenge for healthcare providers. Handling disclosure of the financial details of treatment options in a way that empowers patients, even in the face of extreme poverty, requires careful consideration of the personal preferences and motivations of each patient. This article will consider the high costs of dialysis for patients experiencing extreme poverty in light of various ethical principles, including informed consent and truth-telling. It will conclude that a graduated method of disclosing the physical and financial burdens of each treatment option is the best way forward, particularly for healthcare workers engaged in resource-limited settings.

Dialysis prescription: Determinants and relationship with intradialytic complications and the dialysis dose. A prospective study

Introduction: Dialysis still remains the most common modality for the treatment of end stage kidney disease and it could be maneuvered to augment its dose, minimize complications and improve outcome. Dialysis prescription is a brief of how dialysis is to be given and involves adjustments in patients' characteristics, disease or dialytic procedure. This study aimed to assess the determinants of the prescribed dialysis and its relationship with intradialytic complications and the dialysis dose. Methods: A prospective study in which 1248 sessions for 232 consented participants with end stage kidney disease on maintenance hemodialysis were studied from 2017-2020. Biodata was taken, participants were examined and blood samples were taken to determine electrolytes, urea/creatinine and hematocrit. Pearson's correlation was used to determine the strength of association between dialysis dose and some variables. Results: Determinants of the prescribed dose were dialysis frequency (P<0.001), and predialysis systolic blood pressure (P<0.001) and packed cell volume (P<0.001). Dialysis sessions without significant intradialytic blood pressure changes were most likely to be completed, as sessions with intra-dialysis hypotension were most likely to be terminated. Participants dialyzed with high flux dialyzers, via an arterovenous fistula, higher blood flow and ultrafiltration rates had higher dialysis doses (P<0.001 in all instances). Conclusion: Higher dialysis doses were achieved with higher blood flow and ultrafiltration rates. Intradialytic hypotension was common with dialysis termination, higher blood flow and ultrafiltration rates. Intradialytic hypertension was common with low flux dialyzers. An optimized dialysis prescription is needed to deliver an adequate dialysis dose and minimize complications

Pattern of acute kidney injury and its outcome in a tertiary care centre

Background: Acute kidney injury is a multiplex disease with severe morbidity and mortality. The trends of acute kidney injury vary according to the regions and the population under study. The aim of this study is to evaluate the trends of acute kidney injury and its outcome in a tertiary care hospital.Methods: The study was a prospective observational study conducted at a tertiary care hospital in a metropolitan city. A total of 102 patients of acute kidney injury were selected based on the Kidney Disease Improving Global Outcomes guidelines of acute kidney injury. The main trends of acute kidney injury presentation and its outcome were assessed.Results: Of 102 patients admitted, 42 had a sepsis related diagnosis (42.41%), 17 patients (17.16%) had cardiovascular disease related acute kidney injury and 12 patients (12.12%) had developed acute kidney injury due to drugs and poisons. According to RIFLE (risk of renal failure, injury to kidney, failure and loss of function and end-stage kidney disease) category, 43.96% of patients belonged to the risk category and 30.77% to the injury category. Of 34 patients in failure category, 23 recovered and 11 did not recover. Authors compared the trends of acute kidney injury in patients who recovered and who deteriorated. The mean serum creatinine values were 3.42 mg/dl in patients who didn’t recover from acute kidney injury and 2.05 mg/dl in patients who recovered. In patients of the recovered group, the mean urine output value is 783 ml/day; in deterioration group, 445 ml/day.Conclusions: Most common etiologies of acute kidney injury in this study include sepsis, drugs and poisons, cardiovascular diseases and diarrheal diseases in order of occurrence. High serum creatinine at admission and oliguria were the most common factors that contributed to deterioration in acute kidney injury.

Processed and ultra-processed food consumption are related to metabolic markers in hemodialysis subjects / Consumo de alimentos processados e ultraprocessados está relacionado a marcadores metabólicos em indivíduos em hemodiálise

ABSTRACT Objective To investigate the consumption of processed and ultra-processed foods and evaluate its relationship with the nutritional and metabolic status of hemodialysis patients in a single center in Brazil. Methods This cross-sectional study enrolled 73 individuals in hemodialysis (50 men and 23 women, 21-87 years-old). Clinical and lifestyle variables were assessed by a semi-structured questionnaire and dietary data by food frequency questionnaire. Anthropometric and metabolic data are collected from medical records. Results Processed and ultra-processed foods represented 11.0% of daily caloric intake, 53.0% of trans fatty acid, and 12.5% of salt consumed in the study sample. Individuals who had high intake of this food group (≥128.4g/day, median intake) had higher serum phosphorus and pre-dialysis urea values (p=0.038; p=0.013, respectively). Also, individual with higher consumption of processed meat, sausages and ready prepared food had higher pre-dialysis serum urea (p=0.021), while serum potassium was higher among the subjects who consumed more sauces and salt-based seasonings (p=0.002). Conclusion Higher consumption of processed and ultra-processed foods was associated with important biomarkers of metabolic control for hemodialysis subjects, probably due to non-health dietary composition. Nutritional guidelines and intervention strategies must be promoted to reduce consumption of these food-group in thisspecific population.

RESUMO Objetivo Investigar o consumo de alimentos processados e ultraprocessados e avaliar sua relação com o estado nutricional e metabólico de pacientes em hemodiálise em um único centro brasileiro. Métodos Este é um estudo transversal com 73 indivíduos em hemodiálise (50 homens e 23 mulheres, 21-87 anos de idade). As variáveis clínicas e de estilo de vida foram avaliados por um questionário semi-estruturado, bem como dados dietéticos por questionário de frequência alimentar. Dados antropométricos e metabólicos foram coletados de registros médicos. Resultados Os alimentos processados e ultraprocessados representaram 11,0% das calorias diárias, 53,0% dos ácidos graxos trans e 12,5% de sódio consumido na amostra estudada. Os indivíduos que tiveram alta ingestão deste grupo alimentar (≥128,4 g/dia, ingestão mediana) apresentaram maiores valores de fósforo sérico e uréia pré-diálise (p=0,038; p=0,013, respectivamente). Também, indivíduos com maior consumo de carne processada, embutidos e refeições prontas apresentaram maior ureia sérica pré-diálise (p=0,021), enquanto o potássio sérico foi maior entre os indivíduos que consumiram mais molhos e temperos á base de sal (p=0,002). Conclusão O maior consumo de alimentos processados e ultraprocessados foi associado a importantes biomarcadores de controle metabólico para indivíduos em hemodiálise, provavelmente devido à composição dietética não saudável. Orientações nutricionais e estratégias de intervenção devem ser promovidas para reduzir o consumo desses alimentos nessa população específica.

Processed and ultra-processed food consumption are related to metabolic markers in hemodialysis subjects / Consumo de alimentos processados e ultraprocessados está relacionado a marcadores metabólicos em indivíduos em hemodiálise

ABSTRACT Objective To investigate the consumption of processed and ultra-processed foods and evaluate its relationship with the nutritional and metabolic status of hemodialysis patients in a single center in Brazil. Methods This cross-sectional study enrolled 73 individuals in hemodialysis (50 men and 23 women, 21-87 years-old). Clinical and lifestyle variables were assessed by a semi-structured questionnaire and dietary data by food frequency questionnaire. Anthropometric and metabolic data are collected from medical records. Results Processed and ultra-processed foods represented 11.0% of daily caloric intake, 53.0% of trans fatty acid, and 12.5% of salt consumed in the study sample. Individuals who had high intake of this food group (≥128.4g/day, median intake) had higher serum phosphorus and pre-dialysis urea values (p=0.038; p=0.013, respectively). Also, individual with higher consumption of processed meat, sausages and ready prepared food had higher pre-dialysis serum urea (p=0.021), while serum potassium was higher among the subjects who consumed more sauces and salt-based seasonings (p=0.002). Conclusion Higher consumption of processed and ultra-processed foods was associated with important biomarkers of metabolic control for hemodialysis subjects, probably due to non-health dietary composition. Nutritional guidelines and intervention strategies must be promoted to reduce consumption of these food-group in thisspecific population.

RESUMO Objetivo Investigar o consumo de alimentos processados e ultraprocessados e avaliar sua relação com o estado nutricional e metabólico de pacientes em hemodiálise em um único centro brasileiro. Métodos Este é um estudo transversal com 73 indivíduos em hemodiálise (50 homens e 23 mulheres, 21-87 anos de idade). As variáveis clínicas e de estilo de vida foram avaliados por um questionário semi-estruturado, bem como dados dietéticos por questionário de frequência alimentar. Dados antropométricos e metabólicos foram coletados de registros médicos. Resultados Os alimentos processados e ultraprocessados representaram 11,0% das calorias diárias, 53,0% dos ácidos graxos trans e 12,5% de sódio consumido na amostra estudada. Os indivíduos que tiveram alta ingestão deste grupo alimentar (≥128,4 g/dia, ingestão mediana) apresentaram maiores valores de fósforo sérico e uréia pré-diálise (p=0,038; p=0,013, respectivamente). Também, indivíduos com maior consumo de carne processada, embutidos e refeições prontas apresentaram maior ureia sérica pré-diálise (p=0,021), enquanto o potássio sérico foi maior entre os indivíduos que consumiram mais molhos e temperos á base de sal (p=0,002). Conclusão O maior consumo de alimentos processados e ultraprocessados foi associado a importantes biomarcadores de controle metabólico para indivíduos em hemodiálise, provavelmente devido à composição dietética não saudável. Orientações nutricionais e estratégias de intervenção devem ser promovidas para reduzir o consumo desses alimentos nessa população específica.

Anemia and inflammation, a link between end stage kidney disease and left ventricular hypertrophy

Background: Based on Glomerular Filtration Rate (GFR) Chronic Kidney Disease patients are classified into five stages. It starts with early stage of CKD and finally ends with End Stage Kidney Disease (ESKD). Anemia and inflammation are major medical complication in End Stage Kidney Disease and leads cardio vascular complications like LVH.Methods: A cross sectional study carried out over a 2 year period in Department Nephrology and General Medicine OPD, MIMS, Vizianagaram, Andhra Pradesh, India 120 in which 60 are normal healthy individuals and 60 are End stage kidney Disease. In all the participants Serum creatinine, blood urea, Serum Iron, TIBC, TSAT% Serum ferritin, Serum CRP, IL-6 and TNF-α was measured. All the EDTA blood samples were analyzed for complete blood count. Results: The diagnostic criteria for CKD like blood urea and serum creatinine were significantly higher in ESKD. There is a significantly increased level of Left ventricular mass index in ESKD when compared with Control. The mean erythrocyte indices are decreased in ESKD. The mean serum iron, TIBC and TSAT% decreased ESKD. Whereas serum ferritin significant increase in ESKD group and the mean serum CRP IL-6 and TNF-α significant increase in ESKD group when compared with controlConclusion: Present study finding suggested that there is a raised inflammatory marker in ESKD patients due to inflammation and it further changes serum ferritin, serum iron and TIBC. The above altered factors leads to changes in erythrocyte indices and leads to anemia which ends with cardiovascular complication like Left Ventricular Hypertrophy.

Cognitive Impairment in Renal Transplant Recipient: A Prospective Study

Introduction: Kidney transplant recipients, like patients on dialysis, have several risk factors for developing cognitive impairmentsuch as comorbid illness, depression, and lower level of physical activity.Materials and Methods: A total of 25 patients were included to analyze the cognitive status in chronic kidney disease patientbefore and after renal transplant (RT) (6–9 months after renal transplant). Demographic and clinical variables associated withcognitive impairment were also examined.Results: The mean hemoglobin (Hb) before RT was 8.44 g, significant increase after RT 11.56 mgs. The mean blood ureadecreased from 115.60 mgs to 31.60 mgs after RT. Serum creatinine significantly decreased after RT from 8.10 mgs to 1.30 mgs.Blood pressure (BP) after RT decreased to 123.6/80.40 mmHg. Statistically significant changes in attention, anterogradememory, verbal fluency, and word recognition after renal transplant, but there is no statistically significant in language domain.Conclusion: There is a statistically significant increase in Hb level, decrease in serum creatinine and blood urea, and BPcontrol after the renal transplant. Statistically significant changes in attention, anterograde memory, verbal fluency, and wordrecognition after renal transplant, but there is no statistically significant in language domain

Risk factors for peritoneal dialysis drop-out in patients with end-stage kidney disease / 第二军医大学学报

Objective To analyze the baseline detection indicator and clinical data of peritoneal dialysis (PD) patients with end-stage kidney disease (ESKD) and to identify the risk factors for PD drop-out in ESKD patients, so as to provide reference for selecting dialysis modes. Methods The baseline data of 99 ESKD patients starting to receive PD in Changzheng Hospital, Second Military University from July 2011 to July 2012, were analyzed retrospectively. The patients were divided into drop-out group (including patients who were dead and turned to hemodialysis) and continuous PD group according to whether they were dropped out during a follow-up of 3 years. Correlation analysis was done for preoperative examination indices and clinical data to identify the risk factors of PD drop-out. Results Ten renal transplant patients and 6 who were lost in follow-up were excluded and finally there were 83 patients included. Fifty patients were in the continous PD group and 33 patients were dropped out during a 3-year follow-up period, with 19 died and 14 transferred to hemodialysis. Multivariate Cox regression analysis showed that presence of diabetes (P=0.003, HR:3.61, 95% CI:1.57-8.30), hyperphosphatemia (P<0.001, HR:1.65, 95% CI:1.26-2.13), and high serum total bilirubin (P=0.006, HR:1.11, 95% CI:1.03-1.19) were the independent risk factors of PD drop-out. In addition, age (P=0.035, HR:1.05, 95% CI:1.00-1.07) and anemia (P=0.016, HR:0.96, 95% CI:0.94-0.99) were the independent risk factors for all-caused mortality. Conclusion Presence of diabetes, hyperphosphatemia, and high serum total bilirubin are possible independent risk factors of PD drop-out.

Effect of Peritoneal Dialysis Modality on the 1-Year Rate of Decline of Residual Renal Function

PURPOSE: The effect of different peritoneal dialysis (PD) modalities on the decline in residual renal function (RRF) is unclear due to inconsistencies among studies. In particular, the effect of automated peritoneal dialysis (APD) modalities [continuous cyclic peritoneal dialysis (CCPD) and nightly intermittent peritoneal dialysis (NIPD)] on RRF has not been examined in a large cohort. MATERIALS AND METHODS: We conducted a single-center retrospective study to investigate the association between PD modalities and decline in RRF in 142 incident PD patients [34 on CCPD, 36 on NIPD, and 72 on continuous ambulatory peritoneal dialysis (CAPD)]. RRF was measured within 2 months from PD start and at 1 year after PD initiation. RESULTS: The RRF at 1 year after PD initiation was 1.98+/-2.20 mL/min/1.73 m2 in CCPD patients and 3.63+/-3.67 mL/min/1.73 m2 in NIPD patients, which were moderately lower than 4.23+/-3.51 mL/min/1.73 m2 in CAPD patients (p=0.064). Moreover, there was no significant difference in the 1-year rate of decline of RRF between CCPD and NIPD patients, although APD patients had a faster 1-year RRF decline rate than CAPD patients (CCPD and NIPD vs. CAPD: -45.68 and -36.69 vs. 1.17%/year, p=0.045). APD was associated with a more rapid decline in RRF in patients with end-stage renal disease undergoing PD, although multivariate analysis attenuated the significance of this finding (beta=-31.50; 95% CI, -63.61 to 0.62; p=0.052). CONCLUSION: Our results suggest that CAPD might be more helpful than APD for preserving RRF during the first year of dialysis therapy, although there was no significant difference in the 1-year rate of decline of RRF between the two APD modalities.

Psychosocial Factors in Patients with Chronic Kidney Disease / 한양의대학술지

This review article is intended to show and understand psychosocial factors in patients with chronic kidney disease (CKD) including end-stage renal disease (ESRD) on renal replacement therapy. These patients suffered from many psychosocial factors such as depression, sleep disorder, and chronic pain, etc. The prevalence of major depression or a defined psychiatric illness in ESRD patients is not clearly defined, but is roughly estimated between 5% and 50%. Unfortunately many sufferers do not seek treatment, and of those who do, significant numbers are improperly diagnosed or are not appropriately treated. They should be managed by psychiatric medication and interview, because depression could affect medical outcomes in ESRD patients through several mechanisms. Sleep disorders are common in ESRD patients treated with dialysis and are associated with patients' perceptions of quality of life, assessed by diverse measures, as well as depressive mood. Although pain has been considered as a problem for ESRD patients for more than 20 years, few studies exist on this subject. Pain appears to be an undervalued problem for ESRD patients. These psychosocial factors could affect morbidity, mortality and life quality in CKD and ESRD patients. The physicians, especially managing CKD patients, need to consider these factors.

Review of genitourinary tuberculosis with focus on end-stage renal disease / Revisão acerca da tuberculose genitourinária com foco na insuficiência renal crônica terminal

Tuberculosis (TB) is a current public health problem, remaining the most common worldwide cause of mortality from infectious disease. Recent studies indicate that genitourinary TB is the third most common form of extra-pulmonary disease. The diagnosis of renal TB can be hypothesized in a non-specific bacterial cystitis associated with a therapeutic failure or a urinalysis with a persistent leukocyturia in the absence of bacteriuria. We report on the case of a 33-year-old man who presented on admission end stage renal disease (ESRD) secondary to renal TB and a past history of pulmonary TB with important radiologic findings. The diagnosis was based on clinical findings despite all cultures being negative. Empiric treatment with tuberculostatic drugs was started and the patient became stable. He was discharged with no symptom, but without renal function recovery. He is on maintenance hemodialysis three times a week. TB is an important cause of kidney disease and can lead to irreversible renal function loss.

A tuberculose (TB) é um problema atual de saúde pública, persistindo como a causa mais comum de óbito por doenças infecciosas. Estudos recentes indicam que a TB genitourinária é a terceira forma mais comum de doença extra-pulmonar. O diagnóstico da TB renal pode ser suspeito na presença de cistite bacteriana não-específica associada a falha terapêutica ou com exame de urina apresentando leucocitúria persistente na ausência de bacteriúria. Relatamos o caso de um paciente de 33 anos, sexo masculino, que apresentou na admissão insuficiência renal crônica terminal secundária à TB renal, que tinha história prévia de TB pulmonar, com importantes achados radiológicos. O diagnóstico foi baseado nos achados clínicos apesar de todas as culturas terem sido negativas. Tratamento empírico com drogas tuberculostáticas foi iniciado e o paciente evoluiu estável. Foi de alta assintomático, mas sem recuperação da função renal. Ele encontra-se em hemodiálise três vezes por semana. A TB é uma causa importante de doença renal e pode levar à perda irreversível da função renal.

Relatório do censo brasileiro de diálise de 2010 / 2010 report of the Brazilian dialysis census

INTRODUÇÃO: Dados nacionais sobre diálise crônica são essenciais para o planejamento do tratamento de tal enfermidade. OBJETIVO: Apresentar dados do Censo da Sociedade Brasileira de Nefrologia (SBN) sobre os pacientes com doença renal crônica que estavam em diálise de manutenção em 1 de julho de 2010. MÉTODOS: Levantamento dos dados de unidades de diálise de todo o país. A coleta de dados foi feita utilizando questionário preenchido online pelas unidades de diálise do Brasil cadastradas na SBN. RESULTADOS: Das unidades consultadas, 340 (53,3 por cento) responderam ao Censo. A partir dessas respostas foram feitas estimativas nacionais para a população em diálise. Em julho de 2010, o número estimado de pacientes em diálise foi de 92.091. As estimativas nacionais das taxas de prevalência e de incidência de insuficiência renal crônica em tratamento dialítico foram de 483 e 100 pacientes por milhão da população, respectivamente. O número estimado de pacientes que iniciaram tratamento em 2010 foi 18.972. A taxa anual de mortalidade bruta foi de 17,9 por cento. Dos pacientes prevalentes, 30,7 por cento tinham idade igual ou superior a 65 anos; 90,6 por cento estavam em hemodiálise e 9,4 por cento em diálise peritoneal; 35.639 (38,7 por cento) estavam em fila de espera para transplante; 28 por cento eram diabéticos; 34,5 por cento tinham fósforo sérico > 5,5 mg/dL e 38,5 por cento, hemoglobina < 11 g/dL. O cateter venoso era usado como acesso vascular em 13,6 por cento dos pacientes em hemodiálise. CONCLUSÕES: A prevalência de pacientes em diálise tem apresentado aumento progressivo. Os dados dos indicadores da qualidade diálise de manutenção melhoraram em relação a 2009 e destacam a importância do censo anual para o planejamento da assistência dialítica.

INTRODUCTION: National chronic dialysis data are fundamental for treatment planning. OBJECTIVE: To report data of the annual survey of the Brazilian Society of Nephrology about patients with chronic renal failure who were on dialysis in 1 July, 2010. METHODS: A national survey based on data from the country's dialysis centers. Data collection was performed by using a questionnaire filled out online by the dialysis centers. RESULTS: 340 (53.3 percent) centers answered the questionnaire. National data were estimated for the overall dialysis population. In July 2010, the estimated total number of patients on dialysis was 92,091. The estimated prevalence and incidence rates of end-stage chronic kidney disease patients on maintenance dialysis were 483 and 100/million population, respectively. The estimated number of patients starting a dialysis program in 2010 was 18,972. The annual crude mortality rate was 17.9 percent. Of those on maintenance dialysis, 30.7 percent were aged 65 years or older, 90.6 percent were on hemodialysis and 9.4 percent on peritoneal dialysis, 35,639 (38.7 percent) were on a kidney transplant waiting list, 28 percent were diabetics, 34.5 percent had serum phosphorus levels > 5.5 mg/dL, and 38.5 percent had hemoglobin levels < 11 g/dL. Vascular access was through a venous catheter in 13.6 percent of the hemodialysis patients. CONCLUSIONS: The number of end-stage kidney disease patients on maintenance dialysis is increasing in Brazil. Data concerning the indicators of the quality of maintenance dialysis improved compared to the prior year, and they highlight the importance of the census to guide chronic dialysis therapy.

Relationship between Bone Mineral Density, Erythropoiesis, and Calcium-Phosphorus-Parathyroid Hormone Status in End-stage Renal Disease Patients

OBJECTIVES: Abnormal bone turnover and mineralization is the characteristic of the end-stage renal disease (ESRD) patients receiving dialysis treatment. Reduced bone mineral density (BMD) has been reported in ESRD patients in many recent studies. Recent study has demonstrated hypoxia increases the loss of bone mass whereas the use of erythropoietin (EPO) increases bone marrow mesenchymal stem cell in vitro, which is the commonly found in ESRD patients. The objective of the present study is to analyze the relationship between erythropoiesis and calcium, phosphorus, parathyroid hormone (PTH) status in ESRD patients. METHODS: This study was a cross-sectional analysis of 183 ESRD patients (78 males, 105 females) on dialysis with mean age of 52 +/- 13 years and mean dialysis duration of 3.4 +/- 3.0 years. Duration and dose of EPO administration, hemoglobin, serum ferritin, and iron were checked in all subjects. BMD was evaluated by DXA. RESULTS: Age was negatively, and body weight and c-calcium positively associated with spine and femur neck and total hip BMD. Hemoglobin was positively correlated with femur neck and total hip BMD. Total dose of EPO, iPTH, and alkaline phosphatase had no significant association with BMD. However, according to tertile of serum PTH concentration, BMD were worst in third tertile group. In multivariate linear regression analysis, age, weight, and serum PTH affect BMD. CONCLUSIONS: BMD was independently related with age and weight. Hemoglobin correlated positively with femur neck and total hip BMD. However, treatment with EPO had no association with BMD. Increased PTH was related with reduced BMD.

Terapia antihipertensiva en enfermedad renal crónica / Treatment of hypertension in chronic kidney disease

La enfermedad renal crónica (ERC) constituye una de las causas más frecuentes de hipertensión arterial (HTA) secundaria. Existe una nueva clasificación de la ERC basada en la presencia de un daño estructural con o sin un deterioro de la velocidad de filtración glomerular (VFG). La prevalencia de la HTA varía principalmente según la magnitud de la VFG y la etiología de la enfermedad del parénquima renal. Los mecanismos hipertensógenos primordiales son: la retención de sodio e hipervolemia, y la activación del eje renina angiotensina aldosterona. La HTA es también un factor de progresión de la ERC. La terapia se basa en la restricción de sodio, diuréticos y bloqueadores del eje renina angiotensina. Consideraciones farmacológicas y clínicas son fundamentales para un efectivo uso de esta terapia. Los objetivos son la prevención cardiovascular y renal, a través de la obtención de determinados niveles de presión arterial (PA).

Chronic kidney disease (CKD) is one of the most common causes of secondary hypertension (HTN). Currently, there is a new classification of CKD based on the presence of structural damage with or without glomerular filtration rate(GFR) deterioration. The prevalence of HTN in CKD varies mainly depending on the magnitude of the GFR and the etiology of renal parenchymal disease. Main hipertensive mechanisms are: salt retention with fluid overload, and reninangiotensin aldosterona axis activation. HTN is also a factor for CKD progression. The current therapy is based on sodium restriction, diuretics and renin angiotensin system blockers. Pharmacological and clinical precautions are essential foran effective use of this therapy. Objectives are to prevent cardiovascular and renal events, through obtaining certain blood pressure (BP) levels.

Existe evidencia para el inicio de terapias renales sustitutivas a niveles de filtrado glomerular elevado?: [revisión] / Is there evidence for an early start on renal replacement therapy in patients with higher glomerular filtration rate?: [review]

En los Estados Unidos se está notando un incremento del inicio precoz de terapias renales sustitutivas en esta última década. Del 19% de pacientes que iniciaron diálisis con filtrado glomerular por encima de 10 ml/min/1,73m2 en 1996 se ha pasado a un 45%. La presente revisión pretende hacer hincapié en este fenómeno, presentado evidencia referente a ello. No se conocesi existe beneficio alguno para el comienzo precoz de diálisis. Los datos demuestran un incremento de la mortalidad en diálisis precoz que no parece ser debido a las morbilidades de los pacientes con insuficiencia renal crónica terminal. La función renal residual se puede afectar durante la diálisis de inicio comprometiendo la supervivencia del paciente a largo plazo. Finalmente, se expone el posible gasto financiero que esta tendencia acarrea a nuestro sistema de salud. Son necesarios estudios clínicos aleatorizados que den respuestas a estos dilemas...

There is a trend in the last decade for an increase in early initiation in renal replacement therapy in the United States. In 1996 19% of patients initiated dialysis with an estimated glomerular filtration over 10 ml/min/1.73m2 percentage that actually has increase to 45%. This review will show the reasons and evidence behind the current tendencies. There is no factual evidence to support the claim of the beneficial effects in early dialysis starts. Data so far shows increase mortality in early dialysis, unrelated to the co-morbidities of patients with advanced chronic kidney disease. Residual renal function could also be affected by early initiation of dialysis, hampering survival in the long run. Finally will be showing the financial burden to the health system. Randomized clinical trials are needed to answer these questions...

Heterogeneity of carboxyl-terminal parathyroid hormone circulating forms in patients with hyperparathyroidism due to end stage renal disease / Heterogeneidade das formas carboxi-terminal circulantes de paratormônio em pacientes com hiperparatiroidismo devido à insuficiência renal crônica terminal

OBJECTIVE: To study carboxyl-terminal (COOH) parathyroid hormone (PTH) circulating forms in patients with hyperparathyroidism due to end stage renal disease (ESRD). METHODS: An immunometric assay that recognizes both intact and COOH PTH forms was developed. The assay, in conjunction with an intact assay, was used to measure PTH in serum samples obtained from 25 patients with hyperparathyroidism due to ESRD. Samples were also submitted to gel filtration chromatography in a Superdex® 30 1.6 x 60 cm column, and the PTH content in the elution tubes, measured using both assays. RESULTS: Values from 39.000 to 232.300 ng/mL (mean ± sd = 101.680 ± 45.330 ng/mL) were found using the COOH assay (PTH 39-84 was used as standard). Values obtained by the intact PTH assay ranged from 318 to 3.307 ng/mL (1.769 ± 693 ng/mL) with a correlation between assays of 0.462 (p = 0.02). The elution profile obtained using the COOH assay showed a preponderance of forms with MW ranging from 8.500 to 4.500 daltons. The profiles obtained from the 25 patients were very similar. CONCLUSIONS: In patients with hyperparathyroidism due to ESRD circulating PTH levels contain a broad range of molecular forms including COOH with MW ranging from 8.500 to 4.500 daltons. These forms are not recognized by the standard intact PTH assays. The correlation of these findings to the clinical aspects of bone disease in ESRD patients remains to be studied.

OBJETIVO: Estudar as formas carboxi-terminal (COOH) circulantes de paratormônio (PTH) em pacientes com hiperparatiroidismo devido à insuficiência renal crônica (IRC) terminal. MÉTODOS: Foi desenvolvido um ensaio imunométrico que reconhece formas intactas e COOH longas de PTH. Esse ensaio foi utilizado, em conjunto com um ensaio para molécula intacta de PTH, em amostras de 25 pacientes com hiperparatiroidismo devido à IRC. As amostras também foram submetidas à cromatografia de gel filtração em coluna de Superdex® 30 de 1,6 x 60 cm, e o conteúdo de PTH nos tubos de eluato foi medido, empregando-se os dois ensaios. RESULTADOS: Valores entre 39.000 e 232.300 ng/mL (média ± dp = 101,680 ± 45,330 ng/mL) foram obtidos usando-se o ensaio COOH (PTH 39-84 foi utilizado como padrão). Com o ensaio para PTH intacto, os valores distribuíram-se entre 318 e 3,307 ng/mL (1,769 ± 693 ng/mL) com correlação entre ambos de 0,462 (p = 0,02). O perfil cromatográfico obtido com o ensaio COOH mostrou predomínio de formas com PM entre 8.500 e 4.500 daltons. Os perfis cromatográficos dos 25 pacientes foram bastante semelhantes. CONCLUSÕES: Em pacientes com hiperparatiroidismo devido à IRC, os níveis circulantes de PTH contêm um espectro de formas moleculares que incluem formas carboxi-terminais, com PM entre 8.500 e 4.500 daltons. Essas formas não são reconhecidas pelos ensaios de rotina utilizados para a medida de PTH intacto. A correlação entre esses achados e os aspectos clínicos da doença óssea em pacientes com IRC necessita de maiores estudos.

Proteina c reaciiva elevada e hipoalbuminemia: indrome/complejo malnutricion, microinflamacion cronica, ateroesclerosis: significado pronostico en pacientes hemodializados / Elevated C reactive protein and hypoalbuminemia. Complex syndrome: malnourishment: chronic microinflamation, atherosclerosis: prognosis significance in patients under hemodyalisis

La mortalidad persiste muy alta en pacientes en hemodiálisis, su principal causa es la cardio-cerebro-vascular seguida de la infecciosa. Existe un estado micro-inflamatorio crónico evidenciado por la elevación de reactantes de fase aguda, entre ellos, la proteína C reactiva, la cual está asociada a la morbi-mortalidad de causa cardiovascular y general en estos enfermos. La hipoalbuminemia es un marcador de malnutrición y un fuerte predictor de todas las causas de morbilidad y mortalidad en hemodiálisis. El objetivo es determinar la posible influencia de la proteína C reactiva y la hipoalbuminemia sobre los resultados de morbimortalidad. Se realizó un estudio observacional analítico, prospectivo, con un seguimiento de 24 meses, cuyo resultado fue un promedio de edad de 46-60 años; el tiempo promedio en hemodiálisis era de 6-16 años. La prevalencia de cifras elevadas de PCR fue de 42,99 %, (IC 95%: 22,42-44,25).Existió una correlación inversa entre las cifras de PCR y la albúmina sérica (r=-0,30; p=0,01) y una correlación directa entre PCR y la edad (r=0,27; p=0,02). El tipo de acceso vascular, (PTFE y catéter), guarda relación con los títulos elevados de PCR (p=0,01). La mayorhospitalización (55,6 %), ocurrió en enfermos con PCR elevada (OR: 2,50, IC95%: 2,02-3,14). La hipoalbuminemia es un predictor independiente de la mortalidad general (OR: 2,44). La PCR constituyó un predictor independiente de mortalidad cardiovascular (OR: 2,76, IC 95%: 2,25-3,61). En conclusión se determina la influencia de la PCR y de la hipoalbuminemia sobre la morbimortalidad en enfermos en hemodiálisis.

Mortality is very hight in patients with end-stage renal disease. The leading cause of death is cardiovascular disease and sepsis. The presence of micro-inflammation, is evidenced by increased levels the acute-phase proteins (C-reactive protein), has been found to be associated with vascular disease in dialysis patients Hypoalbuminemia, ascribed to malnutrition, has been one of the most powerful risk factors that predict all-cause and cardiovascular morbidity and mortality in dialysis patients. The purpose of this study was to describe the prognostic significance in haemodialysis patients with this state. The prospectively study in 107 ESRD patients receiving chronic haemodialysis treatment cohort was then followed-up prospectively for 24 month are formulate. The prevalence of hight PCR are 42,99 %,(22,42-44,25), of hypoalbuminemia 33,33%,(22,42-44,25), were also independently predictive of cardiovascular hospitalization ,hs-CRP (OR: 2,50, IC 95% 2,02-3,14), albumin (OR: 1,50, IC 95% 1,21-2,79), and non cardiovascular hospitalization: tunneled catheter as opposed to a fistula (OR: 11,23, IC 95% 7,42-17,03), hs-CRP (OR: 10,43, IC 95%6,72-16,17), and were also independently predictive of cardiovascular mortality CRP (OR: 2,79, IC 95% 2,25-3,61), non albumin (OR: 0,80, IC 95% 0,70-0,92), and non cardiovascular hospitalization: tunneled catheter as opposed to a fistula (OR: 9,35, IC 95% 6,43- 11,21). Increased in a single circulating inflammatory proteins(hs-CPR) and decreced the albumin levelspredict determine a worse prognosis in hemodialysis patients.

Mudança do nível de qualidade de vida em portadores de insuficiência renal crônica terminal durante seguimento de 12 meses / Change in the level of quality of life in end-stage kidney patients during a 12 months follow-up

OBJETIVO: Entre as doenças crônicas, a insuficiência renal crônica terminal (IRCT) se destaca no impacto negativo sobre a qualidade de vida (QV). O estudo teve como objetivo verificar mudança de QV em portadores de IRCT em hemodiálise durante 12 meses e identificar variáveis associadas com piora ou melhora de QV. MÉTODOS: A amostra foi constituída por uma coorte de 93 pacientes de uma mesma unidade hospitalar localizada no interior do Ceará, Brasil. O instrumento Medical Outcomes Study Questionaire 36-Item Short Form Health Survey (SF-36) foi aplicado em 2004 e 2005 para medida de QV com pontuações de 0 (pior) a 100 (melhor) referentes a oito dimensões e dois componentes resumidos (físico e mental). A amostra foi estratificada em três categorias: sem mudança, com melhora e sem piora de QV de acordo com a variação dos dois componentes resumidos (físico e mental). RESULTADOS: Houve variação média positiva (melhora) das pontuações referentes à dimensão Limitação por Aspectos Emocionais (36,0 ± 40,1 vs. 57,0 ± 45,7; p=0,004) e ao Componente Mental Resumido (53,4 ± 22,2 vs. 61,6 ± 23,5; p=0,021). Pacientes com variação negativa (piora) referente ao Componente Mental encontravam-se há menos tempo em diálise quando comparados com os pacientes sem mudança (36,4 ± 32,9 vs. 74,0 ± 54,8 meses; p=0,008). CONCLUSÃO: Maior tempo em diálise se associou com melhora de aspectos mentais de QV em portadores de IRCT. Adaptação psicológica, como ocorre em outras doenças crônicas, poderia ser a explicação para esse resultado.

OBJECTIVE: Among chronic diseases, end-stage kidney disease (ESRD) is distinguished for its negative impact on quality of life (QoL). This study intended to verify change of QoL in ESRD patients on hemodialysis during 12 months and identify factors associated with worsening or improvement of QoL. METHODS: The sample comprised a cohort of 93 patients from a single hospital located in the State of Ceará, Brazil. The Medical Outcomes Study Questionnaire 36-Item Short Form Health Survey (SF-36) was administered in 2004 and 2005 to measure QoL in 8 dimensions and 2 components (physical and mental) scaled from 0 (worst) to 100 (best). The sample was stratified into three categories: no change, improvement and worsening of QoL according to physical and mental components. RESULTS: There was positive mean variation (improvement) of the score due to the dimension Role-emotional (36.0 ± 40.1 vs. 57.0 ± 45.7; p=0.004) and Mental Component (53.4 ± 22.2 vs. 61.6 ± 23.5; p=0.021). Patients with a negative variation (worsening) due to Mental Component had been on hemodialysis for less time when compared to patients with no change (36.4 ± 32.9 vs. 74.0 ± 54.8 months; p=0.008). CONCLUSIONS: In ESRD patients a longer time on hemodialysis was associated with improvement in mental aspects of QoL. Psychological adaptation, which occurs in other chronic diseases, could be the explanation of this outcome.

End stage renal disease: Fight or flight?

Dialysis is one of the treatment options for ESRD. Several investigators have estimated that depression occurs in about 20 to 30 percent of dialysis patients. The treatment of End Stage Renal Disease (ESRD) successfully prolongs the survival of patients with kidney disease but requires that ESRD patients cope with frequent deleterious changes in their health and life situation and shortened survival. Several studies on coping up mechanisms of ESRD patients were collected and reviewed. Self-management of everyday life entailed achieving/maintaining "normalcy" in everyday roles and functioning. Meaning in life is an important motivator in the coping process. Understanding their own needs and accepting support from members of his family and health care community can help them have a quality life.