Educación alimentaria en pacientes en dialisis / Nutritional education in dialysis patients

La enfermedad renal crónica terminal aumenta el riesgo cardiovascular y puede ocasionar defectos en la mineralización ósea. Para prevenir esto, se debe mantener el fósforo plasmático normal, que depende de la diálisis, los quelantes y la ingesta de fósforo, principalmente de origen inorgánico, incorporado mediante aditivos alimentarios. Las intervenciones nutricionales son pilares en el tratamiento de estos pacientes. El objetivo es facilitar estrategias alimentarias a un grupo de pacientes pediátricos en diálisis, mediante educación alimentaria nutricional, para aumentar el consumo de alimentos naturales, disminuyendo la ingesta de fósforo inorgánico especialmente de los productos cárnicos procesados. Materiales y métodos: se estudió una población pediátrica en diálisis. Se preparó un programa educativo con atención personalizada, instrucción alimentaria y seguimiento mensual, seguido de un taller. Resultados: n: 17 pacientes, edad decimal media de 12,3, 53% sexo masculino, 88% en hemodiálisis. Previo a la intervención el 64,7% consumía productos cárnicos procesados. Luego del taller el 58,8% disminuyó su consumo, el 41,2% aumentó la ingesta de preparaciones caseras, el 53% incorporó nuevos condimentos, de los cuales el 89% presentó al incorporarlos, mejor aceptación a las preparaciones. Conclusiones: la hiperfosfatemia está presente en alrededor del 50% de los pacientes en diálisis asociándose a un incremento entre 20% al 40% del riesgo de mortalidad. La presencia de fósforo oculto en los alimentos y la falta de adherencia hacen prioritario trabajar en programas educativos que favorezcan el aprendizaje colaborativo, centralizados en prácticas culinarias, para brindar herramientas que faciliten una alimentación natural, disminuyendo el consumo de ultraprocesados (AU)

Chronic end-stage renal disease increases the risk of cardiovascular disease and may lead to defects in bone mineralization. In order to prevent these risks, normal plasma phosphorus levels should be maintained. Achieving this goal depends on dialysis, chelators, and phosphorus intake, mainly of inorganic origin, incorporated through food supplements. Nutritional interventions are crucial in the treatment of these patients. The objective is to facilitate nutritional strategies to a group of pediatric dialysis patients, through food education, to increase the consumption of natural foods, decreasing the intake of inorganic phosphorus, especially from processed meat products. Materials and methods: a pediatric population undergoing dialysis was studied. An educational program was prepared with personalized care, nutritional instruction, and monthly follow-up visits, followed by a workshop. Results: n: 17 patients, mean age 12.3 years, 53% male, 88% on hemodialysis. Prior to the intervention, 64.7% consumed processed meat products. After the workshop, 58.8% decreased their consumption, 41.2% increased the intake of homemade food, 53% incorporated new seasonings, of whom 89% reported better acceptance of the preparations when they were incorporated. Conclusions: hyperphosphatemia is observed in around 50% of patients undergoing dialysis and is associated with a 20% to 40% increased risk of mortality. The presence of hidden phosphorus in food and the lack of adherence point to the need for the development of educational programs that promote collaborative learning, focusing on food-preparation practices. These programs should provide tools that facilitate a natural diet, reducing the consumption of ultra-processed food (AU)

Hipoparatiroidismo y calcificaciones cerebrales: reporte de caso / Hypoparathyroidism and brain calcifications: a case report

Introducción. El hipoparatiroidismo es una enfermedad caracterizada por la ausencia o concentraciones inadecuadamente bajas de hormona paratiroidea (PTH), que conduce a hipocalcemia, hiperfosfatemia y excreción fraccional elevada de calcio en la orina. Las calcificaciones del sistema nervioso central son un hallazgo frecuente en estos pacientes. Caso clínico. Mujer de 56 años con antecedente de hipotiroidismo, que ingresó por un cuadro de 6 días de evolución caracterizado por astenia, parestesias periorales y movimientos anormales de manos y pies. Las pruebas de laboratorio demostraron hipocalcemia, hiperfosfatemia y niveles bajos de hormona paratiroidea. Se realizó una tomografía computarizada de cráneo que mostró áreas bilaterales y simétricas de calcificaciones en hemisferios cerebelosos, ganglios basales y corona radiata. No se evidenciaron trastornos en el metabolismo del cobre y hierro. Se estableció el diagnóstico del síndrome de Fahr secundario a hipoparatiroidismo y se inició tratamiento con suplementos de calcio y vitamina D con evolución satisfactoria. Discusión. El síndrome de Fahr es un trastorno neurológico caracterizado por el depósito anormal de calcio en áreas del cerebro que controlan la actividad motora. Se asocia a varias enfermedades, especialmente, hipoparatiroidismo. La suplementación con calcio y vitamina D con el objetivo de normalizar los niveles plasmáticos de estos cationes es el tratamiento convencional. (AU)

Introduction. Hypoparathyroidism is a disease characterized by absence or inappropriately low concentrations of circulating parathyroid hormone, leading to hypocalcaemia, hyperphosphataemia and elevated fractional excretion of calcium in the urine. Central nervous system calcifications are a common finding in these patients. Case report. 56-year-old woman with a history of hypothyroidism who was admitted for a 6-day course of illness characterized by asthenia, perioral paresthesias, and abnormal movements of the hands and feet. Laboratory tests showed hypocalcemia, hyperphosphatemia, and low parathyroid hormone levels. A cranial computed tomography was performed. It showed bilateral and symmetrical areas of calcifications in the cerebellar hemispheres, basal ganglia, and radiata crown. No disorders of copper or iron metabolism were evident. The diagnosis of Fahr syndrome secondary to hypoparathyroidism was established and treatment with calcium and vitamin D supplements was started with satisfactory evolution. Discussion. Fahr's syndrome is a neurological disorder associated with abnormal calcium deposition in areas of the brain that control motor activity. It is associated with various diseases, especially hypoparathyroidism. The conventional treatment is supplementation with calcium and vitamin D, with the aim of normalizing their plasma levels. (AU)

Recomendaciones para el manejo de la lisis tumoral / Recommendations for tumor lysis syndrome management

El síndrome de lisis tumoral representa una complicación potencialmente letal provocada por la liberación masiva de ácidos nucleicos, potasio y fosfato hacia la circulación como resultado de la lisis de células neoplásicas, las cuales se caracterizan por una rápida capacidad de proliferación y alta sensibilidad a fármacos. Esto puede ocurrir de forma espontánea antes del inicio del tratamiento y agravarse luego de haberse iniciado la quimioterapia. Presenta una alta mortalidad. Su prevención continúa siendo la medida terapéutica más importante. El cuadro clínico se caracteriza por la existencia de trastornos del metabolismo hidroelectrolítico, en particular, hipercalemia, hiperfosfatemia e hiperuricemia y por la aparición de una lesión renal aguda. Una adecuada intervención terapéutica implica hidratación intravenosa y medidas para prevenir o corregir las alteraciones metabólicas. En este artículo, se proponen lineamientos para seguir tanto en la etapa diagnóstica como en el tratamiento de esta complicación.

The tumor lysis syndrome represents a potentially lethal complication caused by the massive release of nucleic acids, potassium and phosphate into the circulation as a result of the lysis of neoplastic cells, which are characterized by a rapid proliferation capacity and high sensitivity to drugs. This may occur spontaneously prior to the start of treatment, becoming worse after the initiation of chemotherapy. It presents a high mortality; its prevention continues being the most important therapeutic measure. The clinical picture is characterized by the existence of hydroelectrolytic metabolism disorders, in particular hyperkalemia, hyperphosphatemia and hyperuricemia and by the appearance of an acute renal lesion. Adequate therapeutic intervention involves intravenous hydration and measures to prevent or correct metabolic alterations. This article proposes guidelines to follow both in the diagnostic stage and in the treatment of this complication.

The impact of cinacalcet in the mineral metabolism markers of patients on dialysis with severe secondary hyperparathyroidism / Impacto de cinacalcete em marcadores do metabolismo mineral de pacientes em diálise portadores de hiperparatireoidismo secundário grave

Abstract Introduction: Treating secondary hyperparathyroidism (SHPT), a common condition associated with death in patients with chronic kidney disease, is a challenge for nephrologists. Calcimimetics have allowed the introduction of drug therapies no longer based on phosphate binders and active vitamin D. This study aimed to assess the safety and effectiveness of cinacalcet in managing chronic dialysis patients with severe SHPT. Methods: This retrospective study included 26 patients [age: 52 ± 12 years; 55% females; time on dialysis: 54 (4-236) months] on hemodialysis (N = 18) or peritoneal dialysis (N = 8) with severe SHPT (intact parathyroid hormone (iPTH) level > 600 pg/mL) and hyperphosphatemia and/or persistent hypercalcemia treated with cinacalcet. The patients were followed for 12 months. Their serum calcium (Ca), phosphorus (P), alkaline phosphatase (ALP), and iPTH levels were measured at baseline and on days 30, 60, 90, 180, and 365. Results: Patients with hyperphosphatemia (57.7%), hypercalcemia (23%), or both (19.3%) with iPTH > 600 pg/mL were prescribed cinacalcet. At the end of the study, decreases were observed in iPTH (1348 ± 422 vs. 440 ± 210 pg/mL; p < 0.001), Ca (9.5 ± 1.0 vs. 9.1 ± 0.6 mg/dl; p = 0.004), P (6.0 ± 1.3 vs. 4.9 ± 1.1 mg/dl; p < 0.001), and ALP (202 ± 135 vs. 155 ± 109 IU/L; p = 0.006) levels. Adverse events included hypocalcemia (26%) and digestive problems (23%). At the end of the study, 73% of the patients were on active vitamin D and cinacalcet. Three (11.5%) patients on peritoneal dialysis did not respond to therapy with cinacalcet, and their iPTH levels were never below 800 pg/mL. Conclusion: Cinacalcet combined with traditional therapy proved safe and effective and helped manage the mineral metabolism of patients with severe SHPT.

Resumo Introdução: O tratamento do hiperparatireoidismo secundário (HPTs), patologia comum e associada à mortalidade na doença renal crônica, é um desafio para o nefrologista. Advento dos calcimiméticos propiciou terapêutica medicamentosa diferente da usual, baseada em quelantes de fósforo e vitamina D ativa. O objetivo deste estudo foi avaliar segurança e efetividade de cinacalcete no controle do HPTs grave de pacientes em diálise crônica. Métodos: Estudo retrospectivo 26 pacientes [idade: 52 ± 12 anos; 55% mulheres; tempo em diálise: 54 (4-236) meses], em hemodiálise (N = 18) ou diálise peritoneal (N = 8), com HPTs grave (nível de paratormônio intacto (PTHi) > 600 pg/mL), com hiperfosfatemia e/ou hipercalcemia persistentes, em tratamento com cinacalcete. Período de seguimento de 12 meses. Avaliados níveis séricos de cálcio (Ca), fósforo (P), fosfatase alcalina (FA) e PTHi no início do seguimento, 30, 60, 90, 180 e 365 dias. Resultados: Indicações para início do cinacalcete: hiperfosfatemia (57,7%), hipercalcemia (23%), ou ambos (19,3%) com PTH > 600 pg/mL. Ao final do seguimento, observada redução dos níveis PTHi (1348 ± 422 vs. 440 ± 210 pg/mL; p < 0,001), Ca (9,5 ± 1,0 vs. 9,1 ± 0,6 mg/dl; p = 0,004), P (6,0 ± 1,3 vs. 4,9 ± 1,1 mg/dl; p < 0,001) e FA (202 ± 135 vs. 155 ± 109 UI/L; p = 0,006). Eventos adversos: hipocalcemia (26%) e queixas digestivas (23%). No fim do estudo, 73% pacientes utilizavam vitamina D ativada associada ao cinacalcete. Três (11,5%) pacientes, todos em DP, não responderam ao cinacalcete, mantendo níveis PTHi > 800 pg/mL. Conclusão: Utilização de cinacalcete, associado à terapia tradicional, em pacientes com HPTs grave foi segura, eficiente e associada a melhor controle do metabolismo mineral.

Hiperfosfatasemia transitoria benigna de la infancia, reporte de un caso / Benign transient hyperphosphatasemia of childhood: a case report

La Hiperfosfatasemia Transitoria Benigna (HTB) es la causa más frecuente de elevación aislada de la Fosfatasa Alcalina (FA) en la población pediátrica. Es relevante tener la sospecha de esta entidad dada su frecuencia, carácter auto limitado y fácil diagnóstico, a pesar de esto, es poco conocida y estudiada en la Pediatría. Su clínica se asocia a niños sanos como a infecciones virales respiratorias, gastrointestinales y al retraso ponderal. El presente trabajo tiene como objetivo reportar un caso clínico y revisar el diagnóstico de la HBT.

Benign Transient Hyperphosphatasemia (BTH) is the most frequent cause of isolated elevation of Alkaline Phosphatase (AF) in the pediatric population. It is relevant to have the suspicion of this entity given its frequency, self limited character and easy diagnosis, despite this, it is little known and studied in Pediatrics. Its symptoms are associated with healthy children, such as viral respiratory, gastrointestinal infections and delayed weight gain. The objective of this work is to report a clinical case and review the diagnosis of HBT.

Seudohipoparatiroidismo 1b / Pseudohypoparathyroidism 1b

RESUMEN El seudohipoparatiroidismo 1b se caracteriza por resistencia aislada a la parathormona, en ausencia de las manifestaciones típicas de la osteodisfrofia hereditaria de Albright; debido a alteraciones epigenéticas del locus GNAS. Puede presentarse de forma esporádica, o heredado de manera autosómico dominante por vía materna. Se presenta paciente masculino de 31 años, con antecedentes de tumores óseos y calcificaciones cerebrales diagnosticados a los 14 años; que se consulta por presentar mareo intenso, rigidez del cuello y la boca, dificultad para hablar y tragar, desorientación y trastornos de percepción; con fenotipo y somatometría normales, y signos de tetania latente (Chvostek y Trouseau positivos). Los estudios realizados mostraron: hipocalcemia, hiperfosfatemia, aumento de niveles de parathormona y múltiples calcificaciones en cerebro y cerebelo. Con tales hallazgos se emite el diagnóstico de seudohipoparatiroidismo 1b, el cual se confirma mediante pruebas moleculares con alteración en el patrón de metilación en el locus GNAS. No presentó alteraciones en el estudio de secuenciación de los 13 exones codificantes del GNAS. Se concluyó como un caso esporádico ante la ausencia de historia familiar de hipocalcemia, combinado con amplia pérdida de metilación del gen GNAS y la no evidencia de deleciones. Se presenta el primer reporte de esta enfermedad en Cuba con estudio molecular(AU)

ABSTRACT Pseudohypoparathyroidism 1b is characterized by isolated resistance to parathormone, in the absence of the typical manifestations of hereditary Albright osteodysphrophy; due to epigenetic alterations of the GNAS locus. It can occur sporadically, or inherited in an autosomal dominant way through the mother. We report the case of a 31-year-old male patient, with history of bone tumors and cerebral calcifications diagnosed at age 14. She came to consultation due to severe dizziness, stiff neck and mouth, difficulty speaking and swallowing, disorientation and perception disorders; he showed normal phenotype and somatometry, and signs of latent tetany (positive Chvostek and Trouseau). Studies have shown hypocalcaemia, hyperphosphatemia, increased levels of parathormone and multiple calcifications in the brain and cerebellum. These findings, pseudohypoparathyroidism 1b is diagnosed confirmed by molecular tests showing alteration in the methylation pattern in the GNAS locus. There were no alterations in the sequencing study of the 13 exons coding for GNAS. It was concluded as a sporadic case in the absence of a family history of hypocalcemia, combined with extensive loss of GNAS gene methylation and no evidence of deletions. This is the first report this disease with molecular study in Cuba(AU)

Effectiveness of sucroferric oxyhydroxide in patients on on-line hemodiafiltration in real-world clinical practice: A retrospective study / Eficácia do oxihidróxido sucroférrico em pacientes em hemodiafiltração on-line na realidade da prática clínica: um estudo retrospectivo

Abstract Introduction: Hyperphosphatemia is a serious consequence of chronic kidney disease and has been associated with an increased risk for cardiovascular disease. Controlling serum phosphorus levels in patients on dialysis is a challenge for the clinicians and implies, in most cases, the use of phosphate binders (PB). Part of the reason for this challenge is poor adherence to treatment because of the high pill burden in this patient group. Objective: To assess the real-world effectiveness of sucroferric oxyhydroxide (SO) in controlling serum phosphorus levels and determine the associated pill burden. Methods: A multicenter, quantitative, retrospective, before-after study was conducted with patients receiving online hemodiafiltration. Patients who switched to SO as a part of routine care were included in the study. PB treatment, number of pills, serum phosphorus levels, and intravenous iron medication and dosage were collected monthly during the six months of treatment with either PB or SO. Results: A total of 42 patients were included in the study. After switching from a PB to SO, the prescribed pills/day was reduced 67% from 6 pills/day to 2 pills/day (p < 0.001) and the frequency of pill intake was lowered from 3 times/day to 2 times/day (p < 0.001). During the treatment with SO, the proportion of patients with serum phosphorus ≤ 5.5 mg/dL increased from 33.3% at baseline to 45% after six months of treatment. Conclusion: During the six-month follow-up with SO, serum phosphorus levels were controlled with one third of the pills/day compared to other PB.

Resumo Introdução: A hiperfosfatemia é uma grave consequência da doença renal crônica associada a risco aumentado de doença cardiovascular. O controle dos níveis séricos de fósforo dos pacientes em diálise é um desafio que requer, na maioria dos casos, o uso de quelantes de fosfato (QF). Parte da dificuldade se deve à baixa adesão ao tratamento oriunda do grande número de medicamentos receitados para esse grupo de pacientes. Objetivo: Avaliar a real eficácia do oxihidróxido sucroférrico (OHS) no controle dos níveis séricos de fósforo e determinar a carga de comprimidos associada. Métodos: Estudo multicêntrico, quantitativo, retrospectivo, antes e depois conduzido com pacientes em hemodiafiltração on-line. Pacientes remanejados para OHS como parte dos cuidados de rotina foram incluídos no estudo. Tratamento com QF, número de comprimidos, níveis séricos de fósforo, reposição férrica endovenosa e dosagens foram registrados mensalmente durante seis meses de tratamento com QF ou OHS. Resultados: Foram incluídos 42 pacientes no estudo. Após a mudança de QF para OHS, o número de comprimidos prescritos por dia caiu em 67%, de seis para duas unidades diárias (p < 0,001). A frequência de ingestão de comprimidos caiu de três para duas vezes ao dia (p < 0,001). Durante o tratamento com OHS, o percentual de pacientes com fósforo sérico ≤ 5,5 mg/dL aumentou de 33,3% no início para 45% após seis meses de tratamento. Conclusão: Durante os seis meses de seguimento com OHS, os níveis séricos de fósforo foram controlados com um terço dos comprimidos por dia em relação aos tratamentos com outros QF.

Conhecimento do tratamento de hiperfosfatemia e adesão às orientações nutricionais após intervenção em indivíduos em hemodiálise / Knowledge of the hyperphosphatemia treatment and adhesion to the nutritional orientations after intervention in individuals in hemodialysis

Introdução: O controle da hiperfosfatemia é um desafio no tratamento de pacientes hemodialíticos, sendo um dos principais objetivos a serem alcançados. O acompanhamento nutricional e a prática de atividades educativas contribuem para o sucesso na adesão ao tratamento. Objetivo: Descrever, em indivíduos em hemodiálise, o conhecimento do tratamento da hiperfosfatemia, bem como avaliar o possível impacto das orientações nutricionais nos níveis séricos de fósforo após intervenção nutricional em participantes do programa de HD no Hospital Universitário na cidade de Juiz de Fora, MG. Material e Métodos: Estudo quase-experimental, do tipo antes e depois com 35 pacientes em tratamento hemodialítico, com 18 anos ou mais, de ambos os sexos, em diálise há, pelo menos, dois meses e que haviam passado por, pelo menos, uma consulta com a nutricionista do setor. Foram coletados do prontuário dados sociodemográficos e clínicos e aplicados questionário de frequência alimentar adaptado e recordatório 24h para avaliação do consumo alimentar, além de questões fechadas sobre o conhecimento das causas da hiperfosfatemia, alimentos ricos em fósforo e uso de quelantes. A intervenção foi realizada mediante a utilização de cartilha educativa. Após a intervenção foram verificados os níveis séricos de fósforo, considerando hiperfosfatemia valores >5,5 mg/dL. Resultados: Na amostra, 57,1% (n=20) eram do sexo masculino, com média de idade de 61,8 ± 14,3 anos e tempo médio em diálise de 61,1 ± 68,9 meses. A prevalência de hiperfosfatemia antes da intervenção era de 60% (n=21) e ao final da intervenção houve redução para 25,7% (n=9). Houve diferença na redução dos níveis séricos de fósforo quando comparadas as médias antes e depois da intervenção [(5,9 ± 1,3 mg/dL; 4,9 ± 1,7 mg/dL; p<0,001)]. Conclusão: Os resultados mostraram que a intervenção educativa possivelmente contribuiu para melhorar a compreensão e adesão ao tratamento, tendo um papel complementar no manejo da hiperfosfatemia de pacientes dialíticos.

Introduction: Hyperphosphatemia control is a challenge in the treatment of patients in hemodialysis, which is one of the main objectives to be reached. Nutritional accompaniment and practice of educational activities contribute to the success in the adhesion to the treatment. Objective: Describe, in individuals in hemodialysis, the knowledge of the treatment of hyperphosphatemia, as well as to evaluate the possible impact of nutritional orientations on phosphorus levels after nutritional intervention in participants of the program HD at the University Hospital in the city of Juiz de Fora, MG. Material e Methods: Quasi-experimental study, of the before and after kind with 35 patients in hemodialysis treatment, with 18 years or more, of both sexes, in dialysis for, at least, two months and who have had, at least, one appointment with the nutritionist in this division. Sociodemographic and clinical data was collected from patient records and adapted reminder questionnaires of food frequency in the last 24 hours were applied for assessment of food intake, as well as multiple-choice questions about the knowledge of the causes of hyperphosphatemia, phosphorus-rich food and use of binders. The intervention was made through the use of an educational leaflet. After the intervention, phosphorus serum levels were verified, taking into consideration hyperphosphatemia values >5,5 mg/dL. Results: In the sample, 57.1% (n=20) were male, with mean age of 61.8 ± 14.3 years and mean time in dialysis of 61.1 ± 68.9 months. The prevalence of hyperphosphatemia before the intervention had been of 60% (n=21) and at the end of the intervention there was a reduction to 25.7% (n=9). There was difference in the reduction of phosphorus serum levels when compared to the medians before and after the intervention [(5.9 ± 1.3 mg/dL; 4.9 ± 1.7 mg/dL; p<0,001)]. Conclusion: The results showed that the educational intervention possibly contributed to a better understanding and treatment adherence, having a complementary role in the management of hyperphosphatemia in dialysis patients.

Effect of educational intervention on the quality of life of hyperphosphathemic chronic renal patients on hemodialysis / Efecto de la intervención educativa sobre la calidad de vida de pacientes renales crónicos hiperfosfatémicos en hemodiálisis / Efeito de intervenção educacional na qualidade de vida de pacientes renais crônicos hiperfosfatêmicos em hemodiálise

ABSTRACT Objective: to evaluate the health-related quality of life of hyperphosphatemic chronic renal patients on hemodialysis before and after a nursing educational intervention. Method: a quasi-experimental before-and-after study, conduted with 63 hyperphosphatemic chronic renal patients from a renal unit of the state of Rio Grande do Sul (Brazil). A sociodemographic and clinical characterization form was used, pruritus intensity record, Kidney Disease Quality of Life - Short Form and Nursing Educational Intervention. This included individual guidance, clarification of doubts and a printed manual. Laboratory data and pruritus evaluated before, 30 and 60 days after intervention, and quality of life, before and after two months. Analysis from descriptive and analytical measures. Results: after the intervention, there was a statistical difference between the mean scores of the following dimensions: Physical function, Emotional function, Energy/Fatigue, List of problems/symptoms and Cognitive function. Significant correlation was found in the following dimensions: Physical functioning, Physical function, Pain, General health, Emotional wellbeing, List of problems/symptoms, Effects of kidney disease, Kidney disease overload, Sleep and stimulation by the dialysis team. With the intervention there was a reduction in phosphorus, creatinine, calcium and parathyroid hormone levels. Itching also decreased. Regarding the evaluation of their health, 31.7% considered it "good" and 58.8% "regular" before the intervention; afterwards, 50.8% and 36.5% rated it as "good" and "fair" respectively. Conclusion: nursing educational intervention improves health-related quality of life and health perception of hyperphosphatemic chronic renal patients on hemodialysis.

RESUMEN Objetivo: evaluar la calidad de vida relacionada con la salud de pacientes renales crónicos hiperfosfatémicos en hemodiálisis antes y después de una intervención educativa de enfermería. Método: estudio cuasi experimental del tipo antes y después, realizado con 63 pacientes renales crónicos hiperfosfatémicos de una unidad renal del estado de Rio Grande do Sul (Brasil). Se utilizó un formulario de caracterización sociodemográfica y clínica, registro de intensidad de prurito, Kidney Disease Quality of Life - Short Form y la Intervención Educativa de Enfermería. Esta intervención incluyó orientación individual, esclarecimiento de dudas y un manual impreso. Los datos de laboratorio y de prurito se evaluaron antes de la intervención, y 30 y 60 días después de la misma; y la calidad de vida se evaluó previamente y después de dos meses. El análisis se realizó a partir de medidas descriptivas y analíticas. Resultados: después de la intervención se evidenció una diferencia estadística entre las medias de los puntajes de las siguientes dimensiones: Función física, Función emocional, Energía/Fatiga, Lista de problemas/síntomas y Función cognitiva. Se verificó una correlación significativa entre las siguientes dimensiones: Funcionamiento físico, Función física, Dolor, Salud general, Bienestar emocional, Lista de problemas/síntomas, Efectos de la enfermedad renal, Sobrecarga de la enfermedad renal, y Sueño y Estímulo por parte del equipo de diálisis. Con la intervención se registró una reducción en los niveles de fósforo y creatinina, y un aumento del calcio y de la hormona paratiroidea. El prurito también disminuyó. En relación con la evaluación de su salud, el 31,7% de los participantes la consideraron "buena" y el 58,8% "regular" antes de la intervención; luego de la misma, el 50,8% y el 36,5% la evaluaron como "buena" y "regular", respectivamente. Conclusión: la intervención educativa de enfermería mejora la calidad de vida relacionada con la salud y la percepción de la salud de pacientes renales crónicos hiperfosfatémicos en hemodiálisis.

RESUMO Objetivo: avaliar a qualidade de vida relacionada à saúde de pacientes renais crônicos hiperfosfatêmicos em hemodiálise antes e após uma intervenção educacional de enfermagem. Método: estudo quase experimental do tipo antes e depois, realizado com 63 pacientes renais crônicos hiperfosfatêmicos de uma unidade renal estado do Rio Grande do Sul (Brasil). Utilizado formulário de caracterização sociodemográfica e clínica, registro de intensidade de prurido, Kidney Disease Quality of Life - Short Form e Intervenção Educacional de Enfermagem. Esta compreendeu orientação individual, esclarecimento de dúvida e manual impresso. Dados laboratoriais e prurido avaliados antes, 30 e 60 dias após intervenção, e qualidade de vida, previamente e após dois meses. Análise a partir de medidas descritivas e analíticas. Resultados: após a intervenção evidenciou-se diferença estatística entre as médias dos escores das dimensões Função física, Função emocional, Energia/fadiga, Lista de problemas/sintomas e Função cognitiva. Verificou-se correlação significativa nas dimensões: Funcionamento físico, Função física, Dor, Saúde geral, Bem-estar emocional, Lista de problemas/sintomas, Efeitos da doença renal, Sobrecarga da doença renal, Sono e Estímulo por parte da equipe de diálise. Com a intervenção houve redução nos níveis de fósforo, creatinina, elevação de cálcio e paratormônio. O prurido também diminuiu. Em relação à avaliação de sua saúde, 31,7% a consideraram "boa" e 58,8% "regular" anteriormente à intervenção; após, 50,8% e 36,5% a avaliaram com "boa" e "regular" respectivamente. Conclusão: intervenção educacional de enfermagem melhora a qualidade de vida relacionada à saúde e à percepção de saúde de pacientes renais crônicos hiperfosfatêmicos em hemodiálise.

Neonatal transient pseudohypoparathyroidism: could it be included among inactivating parathyroid hormone (PTH)/PTH-related protein signalling disorders?

We report a case of transient pseudohypoparathyroidism in a full-term newborn that presented at 20 hours of life with hypocalcemic seizures, hyperphosphatemia and raised parathormone levels. The diagnosis of pseudohypoparathyroidism was made according to biochemical investigations. The infant was treated with calcium supplementation and vitamin D analog therapy, and he remained stable and symptom-free with normal serum biochemistries during follow-up. We suggest that transient pseudohypoparathyroidism of the newborn (ntPHP) might be included among inactivating parathyroid hormone (PTH)/PTH-related protein signaling disorders as defined by the classification schema recently proposed by the European Pseudohypoparathyroidism Network. To the best of our knowledge, this is the first report in which the new classification has been applied to a case of ntPHP.

Fracture risk in chronic kidney disease: A Korean population-based cohort study

BACKGROUND: Chronic kidney disease (CKD)-mineral and bone disorder (MBD) and fracture risk are both closely related to declining renal function. Controlling hyperphosphatemia with phosphate binders is a basic principle of CKD-MBD treatment. The aim of this study was to identify differences in fracture risk between pre-dialysis CKD patients and end-stage renal disease (ESRD) on dialysis, and to evaluate the effects of phosphate binders on fracture risk in ESRD patients. METHODS: Data from a total of 89,533 CKD patients comprising CKD diagnosis, dialysis, fracture history, and phosphate binder prescription history from 2012 to 2016 were retrieved from the Health Insurance Review and Assessment Service Database. Multivariate Cox regression analyses were performed to identify whether dialysis or phosphate binders were associated with an increased fracture risk. RESULTS: Overall, the rate of fractures in pre-dialysis CKD patients was 74 per 1,000 patient-years, while that in dialysis patients was 84 per 1,000 patient-years. The risk of fracture in ESRD patients was higher than pre-dialysis CKD patients (hazard ratio, 1.16; 95% confidence interval, 1.12–1.21; P < 0.001) after adjusting for confounding variables. In addition, the fracture risk in patients who were not taking phosphate binders was 20.0% higher compared to ESRD patients taking phosphate binders. CONCLUSION: Fractures were more prevalent in ESRD patients on dialysis than pre-dialysis CKD patients. Use of phosphate binders was associated with a lower fracture risk in ESRD patients.

Long-term effectiveness of cinacalcet in non-dialysis patients with chronic kidney disease and secondary hyperparathyroidism

BACKGROUND: Secondary hyperparathyroidism (SHPT) is a common complication of chronic kidney disease (CKD). Cinacalcet use is controversial in non-dialysis patients. METHODS: This retrospective observational study recruited patients receiving cinacalcet (off-label use) in 2010 and 2011. Patients were followed for three years from the beginning of treatment using an intention-to-treat approach. RESULTS: Forty-one patients were studied: 14 CKD stage 3 (34.1%), 21 CKD stage 4 (51.2%), and 6 CKD stage 5 (14.6%). Median baseline parathyroid hormone (PTH) was 396 (101–1,300) pg/mL. Upon cinacalcet treatment (22 ± 12 months), PTH levels decreased by ≥ 30% in 73.2% of patients (P < 0.001; 95% confidence interval [CI], 59–87%), with a mean time for response of 18.7 months (95% CI, 15.4–22.1). Sixteen patients were followed for 36 months and treated for 32 ± 9 months. Mean reduction in their PTH levels was 50.1% (P < 0.001; 95% CI, 33.8–66.4%) at 36 months, with 62.5% of patients (P < 0.001; 95% CI, 35.9–89.1%) presenting reductions of ≥ 30%. Serum calcium levels decreased from 9.95 ± 0.62 mg/dL to 9.21 ± 0.83 and 9.12 ± 0.78 mg/dL at 12 and 36 months, respectively (P < 0.001). Serum phosphorus levels increased from 3.59 ± 0.43 to 3.82 ± 0.84 at 12 months (P = 0.180), remaining so at 36 months (P = 0.324). At 12 and 36 months, 2 (12.5%) patients experienced hypocalcemia. Meanwhile, 1 (6.3%) and 4 (25.0%) patients reported hyperphosphatemia at 12 and 36 months, respectively. CONCLUSION: Cinacalcet remained effective for at least 36 months in non-dialysis patients with SHPT. Electrolytic disturbances were managed with concurrent use of vitamin D and its analogs or phosphate binders.

¿Puede establecerse hoy un valor de fosfatemia como indicador de calidad del tratamiento dialítico? / Can a phosphatemia value be established today as an indicator of the quality of the dialysis treatment?

INTRODUCCIÓN: El trastorno del metabolismo óseo y mineral constituye una grave complicación de la IRC. Respecto al fósforo, las nuevas Guías KDIGO sugieren disminuirla hiperfosfatemia, sin recomendar un valor determinado. Sin embargo, en Argentina se continúa utilizando como indicador de calidad dialítica (IndCalDial) un valor de fósforo igual o inferior a 5 mg.dl. Nuestro objetivo fue evaluar si un valor fijo de fosfatemia es válido como IndCalDial. MATERIAL Y MÉTODOS: Se realizó un estudio multicéntrico, de corte transversal. Se incluyeron pacientes mayores de 18 años, con más de 90 días en hemodiálisis crónica. Se tabularon datos demográficos y de laboratorio. Según el reactivo empleado en la determinación de fósforo, en 4 centros el límite superior de referencia fue 4.5 mg.dl (Grupo F4.5) y en tres 5.6 mg.dl (Grupo F5.6). RESULTADOS: Se incluyeron 334 pacientes. Edad, sexo, porcentaje con FAV, diabéticos, tiempo en diálisis, Kt/V, Hemoglobina y Albúmina, resultaron semejantes a los del Registro Nacional de Diálisis. La mediana de fosfatemia fue 5.2 mg.dl, (rango: 2.3 a 10.6). Los pacientes hiperfosfatémicos fueron más jóvenes y presentaron mejores niveles de Albúmina. De considerarse como IndCalDial: Fósforo menor a 5 mg.dl, 21 pacientes del Grupo F4.5 (n=154) con fosfatemia entre 4.5 y 5.0 mg.dl no recibirían tratamiento, mientras que en el Grupo F5.6 (n=180), 32 pacientes con fosfatemia entre 5.1 y 5.6 mg.dl deberían recibir tratamiento, a pesar de presentar normofosfatemia. CONCLUSIONES: Debería estandarizarse la determinación de fosfatemia, previo a utilizar un valor fijo como IndCalDial

A post-marketing surveillance study to evaluate the efficacy and safety of Sevelamer Carbonate in the management of Chronic Kidney Disease related Hyperphosphatemia in the Philippines

Introduction@#This is a prospective, post marketing surveillance study that aims to determine the efficacy and safety of sevelamer carbonate in hyperphosphatemic chronic kidney disease (CKD) patients in the Philippines.@*Methods@#Adult CKD patients with serum phosphorous levels >1.78 mmol/L and whose physician had decided to treat with sevelamer carbonate 800 mg were enrolled in the study and followed-up for a minimum of three visits from baseline within a six-month period. The primary endpoint was the change in serum phosphorous levels from baseline to the sixth month. Adverse events were noted and recorded during the treatment period.@*Results@#There were 233 patients included in the study from five centers in Metro Manila from 2010 to 2013. Of the 233 patients, 199 were on chronic dialysis, 33 were not on dialysis, and 1 had no data. There was a statistically significant (P-value <0.0001) reduction in serum phosphorous levels from baseline after treatment with sevelamer carbonate. There were 16 patients reported to have adverse drug reactions, 13 of whom had serious adverse events (SAE) and three were non-serious. Of the 13 patients with SAEs, only one was possibly/probably related to sevelamer carbonate and all three non-SAEs were possibly/definitely related to sevelamer carbonate.@*Conclusion@#The results showed sevelamer carbonate to be effective in lowering serum phosphorous levels and the most common adverse events were related to the gastrointestinal tract (1.4%). There were sixteen patients with adverse events, three of which were non-serious, while 13 were reported to be serious adverse events. Only one was probably related to the drug.

Patient education for hyperphosphatemia management: Improving outcomes while decreasing costs?

No abstract available.

Effects of education on low-phosphate diet and phosphate binder intake to control serum phosphate among maintenance hemodialysis patients: A randomized controlled trial

BACKGROUND: For phosphate control, patient education is essential due to the limited clearance of phosphate by dialysis. However, well-designed randomized controlled trials about dietary and phosphate binder education have been scarce. METHODS: We enrolled maintenance hemodialysis patients and randomized them into an education group (n = 48) or a control group (n = 22). We assessed the patients’ drug compliance and their knowledge about the phosphate binder using a questionnaire. RESULTS: The primary goal was to increase the number of patients who reached a calcium-phosphorus product of lower than 55. In the education group, 36 (75.0%) patients achieved the primary goal, as compared with 16 (72.7%) in the control group (P = 0.430). The education increased the proportion of patients who properly took the phosphate binder (22.9% vs. 3.5%, P = 0.087), but not to statistical significance. Education did not affect the amount of dietary phosphate intake per body weight (education vs. control: −1.18 ± 3.54 vs. −0.88 ± 2.04 mg/kg, P = 0.851). However, the dietary phosphate-to-protein ratio tended to be lower in the education group (−0.64 ± 2.04 vs. 0.65 ± 3.55, P = 0.193). The education on phosphate restriction affected neither the Patient-Generated Subjective Global Assessment score (0.17 ± 4.58 vs. −0.86 ± 3.86, P = 0.363) nor the level of dietary protein intake (−0.03 ± 0.33 vs. −0.09 ± 0.18, P = 0.569). CONCLUSION: Education did not affect the calcium-phosphate product. Education on the proper timing of phosphate binder intake and the dietary phosphate-to-protein ratio showed marginal efficacy.

Letter: Hyperphosphatemia is not significantly associated with increased all-cause mortality in Korean hemodialysis patients

No abstract available.

The authors' reply: Hyperphosphatemia is not significantly associated with increased all-cause mortality in Korean hemodialysis patients

No abstract available.