Relationship between dialysis quality and brain compliance in patients with end-stage renal disease (ESRD): a cross-sectional study

ABSTRACT BACKGROUND: The high number of patients with end-stage kidney disease (ESRD) on hemodialysis makes it necessary to conduct studies aimed at improving their quality of life. OBJECTIVES: To evaluate brain compliance, using the Brain4care method for intracranial pressure (ICP) monitoring, among patients with ESRD before and at the end of the hemodialysis session, and to correlate ICP with the dialysis quality index (Kt/V). DESIGN AND SETTING: Cross-sectional study conducted at a renal replacement therapy center in Brazil. METHODS: Sixty volunteers who were undergoing hemodialysis three times a week were included in this study. Brain compliance was assessed before and after hemodialysis using the noninvasive Brain4care method and intracranial pressure wave morphology was analyzed. RESULTS: Among these 60 ESRD volunteers, 17 (28%) presented altered brain compliance before hemodialysis. After hemodialysis, 12 (20%) exhibited normalization of brain compliance. Moreover, 10 (83%) of the 12 patients whose post-dialysis brain compliance became normalized were seen to present good-quality dialysis, as confirmed by Kt/V > 1.2. CONCLUSIONS: It can be suggested that changes to cerebral compliance in individuals with ESRD occur frequently and that a good-quality hemodialysis session (Kt/V > 1.2) may be effective for normalizing the patient's cerebral compliance.

Health economics of kidney replacement therapy in Singapore: Taking stock and looking ahead

The prevalence of end-stage kidney disease (ESKD) in Singapore remains high and continues to rise. We continue to face major challenges in containing the rising incidence of ESKD and providing sustainable kidney replacement therapy. Our cost projections provide an insight into the present and future, urging a call to action to augment existing initiatives to address the emergent issues.

Comparison of planned-start, early-start and deferred-start strategies for peritoneal dialysis initiation in end-stage kidney disease

INTRODUCTION@#In patients with end-stage kidney disease (ESKD) suitable for peritoneal dialysis (PD), PD should ideally be planned and initiated electively (planned-start PD). If patients present late, some centres initiate PD immediately with an urgent-start PD strategy. However, as urgent-start PD is resource intensive, we evaluated another strategy where patients first undergo emergent haemodialysis (HD), followed by early PD catheter insertion, and switch to PD 48-72 hours after PD catheter insertion (early-start PD). Conventionally, late-presenting patients are often started on HD, followed by deferred PD catheter insertion before switching to PD≥14 days after catheter insertion (deferred start PD).@*METHODS@#This is a retrospective study of new ESKD patients, comparing the planned-start, early-start and deferred-start PD strategies. Outcomes within 1 year of dialysis initiation were studied.@*RESULTS@#Of 148 patients, 57 (38.5%) patients had planned-start, 23 (15.5%) early-start and 68 (45.9%) deferred-start PD. Baseline biochemical parameters were similar except for a lower serum urea with planned-start PD. No significant differences were seen in the primary outcomes of technique and patient survival across all 3 subgroups. Compared to planned-start PD, early-start PD had a shorter time to catheter migration (hazard ratio [HR] 14.13, 95% confidence interval [CI] 1.65-121.04, P=0.016) while deferred-start PD has a shorter time to first peritonitis (HR 2.49, 95% CI 1.03-6.01, P=0.043) and first hospital admission (HR 2.03, 95% CI 1.35-3.07, P=0.001).@*CONCLUSION@#Planned-start PD is the best PD initiation strategy. However, if this is not possible, early-start PD is a viable alternative. Catheter migration may be more frequent with early-start PD but does not appear to impact technique survival.

Death and cardiovascular outcomes in end-stage renal failure patients on different modalities of dialysis

INTRODUCTION@#Cardiovascular morbidity and mortality in end-stage renal failure (ESRF) patients are high. We examined the incidence and predictors of death and acute myocardial infarction (AMI) in ESRF patients on different modalities of dialysis.@*METHOD@#Data were obtained from a population-based database (National Registry Disease Offices) in Singapore. The study cohort comprised all adult patients initiated on dialysis between 2007 and 2012 who were closely followed for the development of death and AMI until September 2014. Cox regression methods were used to identify predictors of death and AMI.@*RESULTS@#Of 5,309 patients, 4,449 were on haemodialysis and 860 on peritoneal dialysis (PD). Mean age of the cohort was 61 (±13) years (44% women), of Chinese (67%), Malay (25%) and Indian (7%) ethnicities. By September 2014, the incidence of all-cause death was 34%; close to a third of the patients died from a cardiovascular cause. Age >60 years and the presence of ischaemic heart disease, diabetes, stroke, peripheral vascular disease and PD were identified as independent predictors of all-cause death. PD patients had lower odds of survival compared to patients on haemodialysis (hazard ratio 1.51, 95% confidence interval 1.35-1.70, P<0.0001). Predictors of AMI in this cohort were older age (>60 years) and the presence of ischaemic heart disease, diabetes, stroke, peripheral vascular disease and current/ex-smokers. There were no significant differences in the incidence of AMI between patients on PD and haemodialysis.@*CONCLUSION@#The short-term incidence of death and AMI remains high in Singapore. Future studies should investigate the benefits of a tighter control of cardiovascular risk factors among ESRF patients on dialysis.

Review of Leachable Substances in Hemodialyzer / 中国医疗器械杂志

With the rapid development of my country's hemodialysis industry, the application of hemodialysis machines has become more and more extensive, but at the same time, the quality control technology of hemodialysis machines is not perfect. Especially for a wide range of leachable substances in dialyzers, there are few studies and detection methods. This study first briefly describes the development of hemodialyzers, and then expounds the common types of leachables, extraction methods, and chromatography and mass spectrometry conditions. It is summarized that the research plan of leachable substances is to determine the type first, then formulate the extraction plan, and then establish the detection method. Finally, we look forward to the research prospects of hemodialyzer leachables, and point out that with the deepening and extensive development of research, it can further promote the healthy development of the hemodialyzer industry.

Biochemical and histopathological evaluations of chronic renal failure rats treated with pluripotent human stem cells

Abstract Regeneration of damaged kidney cells using stem cells is the current research approach in the treatment of chronic renal failure (CRF). In the present study, the histopathological and biochemical techniques were used to evaluate stem cells' (SCs) role in treatment of CRF. Sixty-four rats were divided into eight groups. Group I (GI): rats were injected with doxorubicin (15 mg/kg) to initiate CRF. GII-GVII: rats were injected with doxorubicin and treated with SCs (1x106 MSCs or/and 2x104 HSCs/rat) with/without growth factors extract (200 µL/rat) and/or immunosuppressor (cyclosporine A, 5 mg/kg/day). GVIII: rats treated with PBS (100 µL/kg/day). Levels of creatinine, urea and uric acid were increased in rats sera after injection with doxorubicin, while blood electrolyte levels of Na, K, P and Mg were decreased. Also, histopathological abnormalities such as hyalinized blood vessels, degenerated hyalinized glomerulus tubules and cell debris in the lumen and degeneration of renal tissues were observed in these rats. After treatment with SCs, all these parameters restore their normal values with regeneration of the damaged cells as demonstrated in histopathology of the treated groups. It can be concluded that, the use of SCs in treatment of kidney diseases is a promising approach and needs more efforts.

Quality of life in primary caregivers of patients in peritoneal dialysis and hemodialysis / Qualidade de vida em cuidadores primários de pacientes em diálise peritoneal e hemodiálise

Abstract Background: Peritoneal dialysis (PD) is gaining track as an efficient/affordable therapy in poor settings. Yet, there is little data regarding differences in quality of life (QoL) of primary caregivers (PCG) of patients in PD and hemodialysis (HD). Aim: To compare the QoL of PCG of patients in PD and HD from an upper middle-income population in a Mexican city. Methods: Cross-sectional study was carried out with PCG of patients in PD (n=42) and HD (n=95) from 4 hospitals (response rate=70.2%). The SF 36-item QoL questionnaire, the Zarit burden interview, and the Goldberg anxiety/depression scale were used. Mean normalized scores for each QoL domain were compared by dialysis type. Adjusted odds were computed using logistic regression to determine the probability of low QoL (<70% of maximum possible score resulting from the added scores of the 8 dimensions). Results: The PD group had higher mean scores for emotional role functioning (+10.6; p=0.04), physical functioning (+9.2; p=0.002), bodily pain (+9.2; p=0.07), social functioning (+5.7; p=0.25), and mental health (+1.3; p=0.71); the HD group had higher scores for physical role functioning (+7.9, p=0.14), general health perception (+6.1; p=0.05), and vitality (+3.3; p=0.36). A non-significant OR was seen in multivariate regression (1.51; 95% CI 0.43-5.31). Zarit scores were similar, but workload levels were lower in the PD group (medium/high: PD 7.2%, HD 14.8%). Anxiety (HD 50.5%, PD 19%; p<0.01) and depression (HD 49.5%, PD 16.7%; p<0.01) were also lower in the PD group. Conclusion: Adjusted analysis showed no differences in the probability of low QoL between the groups. These findings add to the value of PD, and strengthen its importance in resource-limited settings.

Resumo Histórico: A diálise peritoneal (DP) vem ganhando terreno como terapia eficiente/acessível em ambientes pobres. Contudo, há poucos dados sobre diferenças na qualidade de vida (QV) dos cuidadores primários (CP) de pacientes em DP e hemodiálise (HD). Objetivo: Comparar QV dos CP de pacientes em DP e HD de uma cidade mexicana de renda média. Métodos: Estudo transversal com CP de pacientes em DP (n=42) e HD (n=95) de 4 hospitais (taxa resposta=70,2%). Aplicou-se o questionário QV-36 itens, entrevista de sobrecarga de Zarit e escala de ansiedade/depressão Goldberg. Escores médios normalizados para cada domínio de QV foram comparados por tipo de diálise. Probabilidades ajustadas foram calculadas usando regressão logística para determinar a probabilidade de baixa QV (<70% da pontuação máxima possível resultante das pontuações adicionadas das 8 dimensões). Resultados: O grupo DP apresentou escores médios mais altos para aspectos emocionais (+10,6; p=0,04), capacidade funcional (+9,2; p=0,002), dor (+9,2; p=0,07), aspectos sociais (+5,7; p=0,25), saúde mental (+1,3; p=0,71); o grupo HD teve pontuação maior para aspectos físicos (+7,9, p=0,14), estado geral de saúde (+6,1; p=0,05), vitalidade (+3,3; p=0,36). Uma probabilidade não significativa foi observada na regressão multivariada (OR=0,66; 95% IC 0,18-2,31). Os escores de Zarit foram semelhantes, mas os níveis da sobrecarga foram menores na DP (médio/alto: DP 7,2%, HD 14,8%). Ansiedade (50,5% vs 19%; p<0,01) e depressão (49,5% vs 16,7%; p<0,01) foram menores na DP. Conclusão: O risco de baixa QV entre grupos não foi diferente na análise ajustada. Estes achados fortalecem a importância da DP em ambientes com recursos limitados.

Rehabilitación del intestino utilizando un análogo semisintético del péptido 2 similar al glucagón. Primera experiencia con teduglutide en Uruguay / Intestinal rehabilitation using semisynthetic glucagon-like peptide-2 analogue. First experience with teduglutide in Uruguay / Reabilitação do intestino usando um análogo semi-sintético do peptídeo 2 semelhante ao glucagon. Primeira experiência com teduglutide no Uruguai

Resumen: La falla intestinal crónica (FIC) o tipo III es una condición invalidante, y la nutrición parenteral crónica (NPC) domiciliaria es el tratamiento que permite a estos pacientes mantenerse con vida. Sin embargo, solamente uno de cada tres países latinoamericanos cuentan con ese recurso, y sus complicaciones no son infrecuentes. Estas complicaciones son las principales indicaciones para trasplante intestinal, un procedimiento que en la mayoría de los países de ingresos medios no se ha desarrollado y no ha presentado los resultados esperados. En los últimos años, la rehabilitación intestinal a nivel mundial ha mejorado sustancialmente con el uso de análogos semisintéticos del péptido 2 similares al glucagón, existiendo cada vez mayor evidencia que demuestra la posibilidad de rehabilitación intestinal e independencia de la NPC con este fármaco, incluso en pacientes con anatomía desfavorable. Estos resultados han permitido mejorar la supervivencia y la calidad de vida de pacientes con FIC y, en muchas ocasiones, prescindir del trasplante. El paciente del caso que presentamos es el primero en recibir esta terapéutica en nuestro país. En este artículo analizamos la respuesta precoz favorable al tratamiento y sus perspectivas a futuro.

Abstract: Long-term home parenteral nutrition (HPN) is a life-saving treatment for patients with chronic intestinal failure, an invalidating condition. However, only 1 out of 3 countries can rely on this treatment and complications associated to chronic parenteral nutrition are rather frequent. The latter constitute the main indication for intestinal transplantion, a procedure that in most middle-income countries has not yet developed and has not shown the expected outcome. In recent years, intestinal rehabilitation has significantly improved at the global level with the use of GLP2, based on the growing evidence that proves the possibility of intestinal rehabilitation and independence from parenteral nutrition with Teduglutide, even in the case of patients with unfavorable anatomy. These results have caused a positive impact on survival and the quality of life of patients with chronic renal failure, and they can often abstain from transplant. The patient of the case study is the first one who received this therapy in our country and this article analyses his favorable early response to treatment and future perspectives.

Resumo: A insuficiência intestinal crônica (CIF) ou tipo III é uma condição incapacitante e a nutrição parenteral crônica (NPC) domiciliar é o tratamento que permite a sobrevida desses pacientes. No entanto, apenas 1 em cada 3 países latino-americanos dispõe desse recurso e as complicações da NPC não são raras. Essas complicações são as principais indicações para o transplante intestinal, procedimento que na maioria dos países de renda média não foi desenvolvido ou não apresentou os resultados esperados. Nos últimos anos, a reabilitação intestinal em todo o mundo tem melhorado substancialmente com o uso de sGLP2, com um número cada vez maior de evidências que mostram a possibilidade de reabilitação intestinal e independência da NPC, mesmo em pacientes com anatomia desfavorável. Esses resultados têm possibilitado prolongar a sobrevida e melhorar a qualidade de vida dos pacientes com CIF e, em muitos casos, dispensar o transplante. O paciente do caso que apresentamos é o primeiro a receber essa terapia em nosso país. Neste artigo, analisamos a resposta favorável ao tratamento precoce e suas perspectivas futuras.

Urgent vs. early-start peritoneal dialysis: patients' profile and outcomes / Diálise peritoneal de urgência vs. início precoce: perfil dos pacientes e resultados

ABSTRACT Introduction: Peritoneal dialysis (PD) has been considered a safe option of therapy in end-stage renal disease patients with urgent need of dialysis. Recently, it was proposed that Urgent-Start-PD (US-PD) be defined when PD starts within 72 hours after catheter placement and "early start" PD (ES-PD) when PD starts between 3 and 14 days after. We aimed to compare demographic and clinical characteristics between patients in US-PD and ES-PD as well as 30-day complications, 6-month hospitalization, and dropout rate. Methods: Adult patients starting PD within 14 days after catheter insertion (October/2016 - February/2019) were included and divided into US-PD group and ES-PD group based on the their PD initiation time. Clinical and demographic data, fill volume for the first PD session, 30-day complications, 6-month hospitalization, and dropout rate were assessed. Results: In our study, 72 patients were analyzed (US-PD=40, ES-PD=32) with mean age of 53.2±15.2 years old. No differences between US-PD and ES-PD regarding demographic characteristics, 30-day complications, 6-month hospitalization, and dropout events were found. The most frequent short-term complication in patients who started PD urgently was leakage. The most common cause of dropout was transfer to HD. Conclusion: Fifty five percent of our sample started PD less than 72 hours after catheter insertion. The lack of difference in the measured outcomes compared to patients that had therapy initiated after this period encourages the use of urgent PD when needed.

RESUMO Introdução: A diálise peritoneal (DP) tem sido considerada uma opção segura de terapia em pacientes com doença renal terminal com necessidade urgente de diálise. Recentemente, foi proposto que a DP de início urgente (US-PD) fosse definida quando a DP iniciar dentro de 72 horas após o implante do cateter, e a DP de "início precoce" (ES-PD) quando a DP iniciar entre 3 e 14 dias após o procedimento. Nosso objetivo foi comparar características demográficas e clínicas entre pacientes em US-PD e ES-PD, bem como complicações em 30 dias, internação por 6 meses e taxa de saída do tratamento. Métodos: Pacientes adultos iniciando DP em até 14 dias após a inserção do cateter (outubro/2016 - fevereiro/2019) foram incluídos e divididos no grupo US-PD ou ES-PD com base no tempo de início da DP. Dados clínicos e demográficos, volume de preenchimento na primeira sessão de DP, complicações em 30 dias, hospitalização por 6 meses e taxa de saída foram avaliados. Resultados: Em nosso estudo, 72 pacientes foram analisados (US-PD = 40, ES-PD = 32) com média de idade de 53,2 ± 15,2 anos. Não foram encontradas diferenças entre US-PD e ES-PD em relação às características demográficas, complicações em 30 dias, hospitalização por 6 meses e saída do tratamento. A complicação de curto prazo mais frequente nos pacientes que iniciaram a DP com urgência foi o extravasamento de líquido peritoneal. A causa mais comum de saída foi a transferência para HD. Conclusão: Mais da metade da nossa amostra iniciou a DP menos de 72 horas após a inserção do cateter. A falta de diferença nos desfechos mensurados em comparação com os pacientes que iniciaram o tratamento após esse período incentiva o uso de US-PD quando necessário.

The spleen size in patients undergoing hemodialysis / O tamanho do baço em pacientes em hemodiálise

Abstract Introduction: Inflammation promotes the progression of chronic renal failure, and the start of dialysis worsens inflammation. The enlargement of the spleen is associated with inflammation, and patients on hemodialysis may show a large spleen. The aim of the present study was to compare the spleen size of patients undergoing hemodialysis versus controls to update this thread. Methods: Controls and patients were eligible to participate in the study provided they were negative for serological markers of hepatitis B and C viruses and HIV, if they had no lymphoproliferative disorder, and if they were at least 18 years of age. Age, sex, and the duration of dialysis were recorded. Laboratory variables (hemoglobin, hematological cell count, serum creatinine) and the underlying cause of end-stage renal disease were analyzed. The spleen sizes of the patients were divided into tertiles. Results: The 75 controls and 168 patients selected were sex-matched. The patients were older, had larger spleens and lower platelet counts than controls. The relationship between spleen size and age in the controls and patients was quite similar. The patients in the first tertile of spleen size compared with those in the third were older and had a higher platelet counts. The underlying disease and dialysis vintage had no effect on spleen size. Discussion: The patients had larger spleens and a greater range of spleen sizes than the controls. In patients, the association between larger and smaller spleen with lower and higher platelet counts, respectively, sparked the speculation of occurrence of hypersplenism and hyposplenism.

Resumo Introdução: A inflamação promove a progressão da insuficiência renal crônica, e o início da diálise agrava a inflamação. O aumento do baço está associado à inflamação e os pacientes em hemodiálise podem apresentar um baço grande. O objetivo do presente estudo foi comparar o tamanho do baço de pacientes em hemodiálise versus aquele de controles, para atualizar este tópico. Métodos: Controles e pacientes foram elegíveis para participar do estudo desde que fossem negativos para marcadores sorológicos dos vírus da hepatite B, C e HIV, se não apresentassem distúrbio linfoproliferativo e tivessem pelo menos 18 anos de idade. Registramos idade, sexo e duração da diálise. Avaliamos as variáveis laboratoriais (hemoglobina, contagem de células hematológicas, creatinina sérica) e a causa básica da doença renal terminal. O tamanho dos baços dos pacientes foram divididos em tercis. Resultados: Os 75 controles e 168 pacientes selecionados foram pareados por sexo. Os pacientes eram mais velhos, tinham baços maiores e menor contagem de plaquetas do que os controles. A relação entre o tamanho do baço e a idade dos controles e pacientes foi bastante semelhante. Os pacientes do primeiro tercil de tamanho do baço, em comparação com os do terceiro, eram mais velhos e apresentavam contagens de plaquetas mais altas. A doença subjacente e o período de diálise não tiveram efeito no tamanho do baço. Discussão: Os pacientes tinham baços maiores e uma maior variedade de tamanhos de baço do que os controles. Entre os pacientes, a associação entre baço maior e menor com contagens de plaquetas mais baixas e mais altas, respectivamente, gerou a especulação da ocorrência de hiperesplenismo e hiposplenismo.

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.

Safety and effectiveness of left atrial appendage occlusion in patients with atrial fibrillation and end-stage renal disease undergoing long-term hemodialysis / 中华心血管病杂志

Objective: To evaluate the safety and effectiveness of left atrial appendage occlusion (LAAO) in patients with atrial fibrillation and end-stage renal disease undergoing long-term hemodialysis. Methods: Six patients with AF and end-stage renal disease(ESRD)on long term hemodialysis who underwent LAAO from March 2017 to March 2021 in Beijing Anzhen Hospital were enrolled. Baseline characteristics such as age, sex, types of arrhythmia, stroke and bleeding score, and continuous dialysis time were collected. Four patients underwent LAAO, two patients underwent the combined procedure of catheter ablation and LAAO. Perioperative treatment and serious complications were recorded. Transesophageal echocardiography was repeated at 45 days and 60 days after the procedure. Telephone follow-up was conducted at 3, 6 and 12 months after the procedure, and every 6 months thereafter. Thromboembolism and major bleeding events and survival were evaluated. Results: The average age was (66.7±17.0) years old, and 5 were male (5/6). There were 4 patients with paroxysmal AF (4/6), and 2 patients with persistent AF (2/6). The mean CHA2DS2-VASc score was (4.8±1.5), and the HAS-BLED score was (3.5±1.4). The duration of hemodialysis was 2.6 (1.1, 8.3) years. Successfully Watchman implantation was achieved in all patients. There were no severe perioperative complications, and no device related thrombosis or leaks were observed by transesophageal echocardiography. During a mean of 22.0 (12.0, 32.0) months follow-up, there was no thromboembolism or major bleeding events. A total of 2 patients died, one from sudden cardiac death, and another one from heart failure. Conclusions: LAAO may be a safe and effective therapeutic option for prevention of thromboembolism in patients with atrial fibrillation and end-stage renal disease undergoing long-term hemodialysis, further studies with larger patient cohort are needed to confirm our results.

Opinions about Death in People Receiving Dialysis

ABSTRACT Objective: People receiving dialysis have a high mortality rate due to life-threatening, chronic renal failure. These patients experience the fear of pain and suffering, loneliness and death in the haemodialysis unit. This research aimed at determining the perception of death in people receiving dialysis. Methods: A cross-sectional, descriptive research was conducted under the supervision of the Ministry of Health in public hospitals in the cities of Mersin, Izmir, Antalya, Erzurum, Samsun and Gaziantep. A total 240 patients were treated in the dialysis units of these hospitals. Participants were selected with stratified random sampling. For data collection, a patient information form was prepared by the researcher. Data from the study were analysed with Tukey Honest Significant Difference and one-way ANOVA, using an SPSS version 11.5 software package (Statistical Package for the Social Sciences Windows, IBM Corp., Armonk, NY). The statistical significance level was defined as p < 0.05. Results: People receiving dialysis were found to be in a mildly depressive emotional state and they had death anxiety. Death-related anxiety and depression were more common among the female study participants compared to the male participants. Single patients exhibited higher levels of death anxiety compared to married patients. Conclusion: We recommend a holistic and personalised care to allow people receiving dialysis to express their feelings and to overcome the death anxiety. Further research is needed to improve dignified person-centred care for people receiving dialysis.

Treatment of tegumentary leishmaniasis in two hemodialysis patients with end-stage renal disease using two series of pentamidine

Abstract In this study, we present two cases of cutaneous leishmaniasis in patients with end-stage renal disease, who were treated solely with intramuscular pentamidine. In such cases, treatment implies a fine line between therapeutic efficacy and toxicity. This is suggestive of a knowledge gap; however, findings indicate that this is still the fastest and safest alternative to the treatment with antimonials. Also, it can help avoid the side effects that occur upon using antimonials.

Non-adherence to hemodialysis, perception of the illness, and severity of advanced nephropathy / Não aderência à hemodiálise, percepção de doença e de gravidade da nefropatia avançada

Abstract Introduction: Hemodialysis (HD) is a complex therapy that imposes several changes in the patient's life. Failure to follow therapy recommendations is called non-adherence (NA). The patient's illness perception, severity of chronic kidney disease, and individual strategies for coping with HD can have an impact on NA to the demands of therapy. Methods: This was a cross-sectional study with end-stage renal disease patients on conventional HD in Salvador, Bahia. We evaluated attendance to treatment and interdialytic weight gain (IDWG) as parameters of NA to HD, and investigated its association with clinical aspects and measures of disease perception (illness effects questionnaire - IEQ) and severity of nephropathy (end stage renal disease severity index - ESRD-SI), by analyzing Pearson or Spearman correlation. Results: 79 patients were evaluated, 57% male, aged 53.1 ± 12.3 years, with length of HD of 108 (89 - 131.5) months. Age correlated with ESRD-SI (r = 0.43) and NA parameters: negative correlation with relative IDWG (r = -0.41) and reduction in sessions (r = -0.31) and positive correlation with %HD performed (r = 0.25). The scores on the IEQ and ESRD-SI showed a positive correlation (r = 0.44; p <0.001), but did not show any correlation with the analyzed NA parameters. Conclusions: We did not find a correlation between illness perception and severity index of advanced nephropathy with the behaviors of NA to chronic HD. In this study, age correlated both with the perception of severity of advanced nephropathy and the parameters of NA to chronic HD.

Resumo Introdução: A hemodiálise (HD) é uma terapia complexa que impõe diversas mudanças à vida do paciente. O não seguimento das recomendações da terapia é denominado não aderência (NA). Percepção do paciente sobre a doença, gravidade de doença renal crônica e estratégias individuais de enfrentamento da HD podem repercutir em NA às demandas da terapia. Métodos: Estudo de corte transversal com pacientes de doença renal em estágio final em HD convencional em Salvador, Bahia. Avaliamos assiduidade ao tratamento e ganho ponderal interdialítico (GPID) como parâmetros de NA à HD, e pesquisamos sua associação com aspectos clínicos e medidas de percepção de doença (IEQ) e de severidade da nefropatia (ESRD-SI), mediante análise de Correlação de Pearson ou Spearman. Resultados: Foram avaliados 79 pacientes, 57% masculino, idade 53,1 ± 12,3 anos, em HD há 108 (89 - 131,5) meses. Idade apresentou correlação com ESRD-SI (r = 0,43) e parâmetros de NA: correlação negativa com GPID relativo (r = -0,41) e redução das sessões (r = -0,31) e correlação positiva com %HD realizada (r = 0,25). As pontuações no IEQ e ESRD-SI demonstraram correlação positiva (r = 0,44; p < 0,001), porém não apresentaram correlação com os parâmetros de NA analisados. Conclusões: Não encontramos correlação entre percepção de doença e índice de gravidade da nefropatia avançada com os comportamentos de NA à HD crônica. Neste estudo, idade teve correlação com percepção de gravidade de nefropatia avançada e parâmetros de NA à HD crônica.

Análisis de sobrevida en pacientes incidentes de hemodiálisis en Chile, 2013-2019

Background: Renal replacement therapies, especially hemodialysis (HD) in end-stage kidney disease, avoid an inevitable death caused by the disease. However, in elderly patients with multiple comorbidities, this therapy could derive in a comparable survival than conservative management. Considering that HD represents a high cost for the health system, it is worth analyzing the effects of HD on survival. Aim: To analyze the survival and mortality of all national health security system's patients (FONASA) admitted to HD in Chile from 2013 to 2019. Material and Methods: We requested to the Ministry of Health information about all patients affiliated to the public health insurance system that started dialysis between 2013 and 2019. We evaluated the influence of age when starting HD, sex, presence of hypertension, presence of diabetes mellitus (DM), the region of residence, and year of admission on mortality. Results: A total of 24,113 patients aged 61 ± 15 years (45% women) were analyzed. Forty five percent of patients were aged > 65 years. After 5 years of follow-up, the median survival in this age group was 36.1 months. Among patients who started HD at age > 85 years, the median survival was 14.8 months. Diabetic patients had a median survival of 52.3 months. Advanced age and DM were associated with higher annual mortality. Also, the region of residence and year of admission were associated with higher mortality at 3 and 12 months. Conclusions: The median survival of patients on HD is dependent on age and the presence of comorbidities, among other factors. We performed an analysis to determine if starting HD in older patients with comorbidities has a real benefit over conservative management in terms of survival.

Prevalence of abnormalities in electrocardiogram conduction in dialysis patients: a comparative study / Prevalência de anormalidades de condução no eletrocardiograma de pacientes em diálise: um estudo comparativo

ABSTRACT Background: The electrocardiogram (ECG) can aid in identification of chronic kidney disease (CKD) patients at high risk for cardiovascular diseases. Cohort studies describe ECG abnormalities in patients on hemodialysis (HD), but we did not find data comparing ECG abnormalities among patients with normal kidney function or peritoneal dialysis (PD) to those on hemodialysis. We hypothesized that ECG conduction abnormalities would be more common, and cardiac conduction interval times longer, among patients on hemodialysis vs. those on peritoneal dialysis and CKD 1 or 2. Methods: Retrospective review of adult inpatients' charts, comparing those with billing codes for "Hemodialysis" vs. inpatients without those charges, and an outpatient peritoneal dialysis cohort. Patients with CKD 3 or 4 were excluded. Results: One hundred and sixty-seven charts were reviewed. ECG conduction intervals were consistently and statistically longer among hemodialysis patients (n=88) vs. peritoneal dialysis (n=22) and CKD stage 1 and 2 (n=57): PR (175±35 vs 160±44 vs 157±22 msec) (p=0.009), QRS (115±32 vs. 111±31 vs 91±18 msec) (p=0.001), QT (411±71 vs. 403±46 vs 374±55 msec) (p=0.006), QTc (487±49 vs. 464±38 vs 452±52 msec) (p=0.0001). The only significantly different conduction abnormality was prevalence of left bundle branch block: 13.6% among HD patients, 5% in PD, and 2% in CKD 1 and 2 (p=0.03). Conclusion: To our knowledge, this is the first study to report that ECG conduction intervals are significantly longer as one progresses from CKD Stage 1 and 2, to PD, to HD. These and other data support the need for future research to utilize ECG conduction times to identify dialysis patients who could potentially benefit from proactive cardiac evaluations and risk reduction.

RESUMO Introdução: O eletrocardiograma (ECG) pode auxiliar na identificação de pacientes com doença renal crônica (DRC) e alto risco para doenças cardiovasculares. Estudos de coorte descrevem anormalidades no ECG de pacientes em hemodiálise (HD), mas não encontramos dados comparando anormalidades no ECG entre pacientes com função renal normal ou aqueles em diálise peritoneal (DP), com aqueles em hemodiálise. Nossa hipótese foi de que as anormalidades de condução no ECG seriam mais comuns, e o intervalo de condução cardíaca seria mais longo entre os pacientes em hemodiálise comparados àqueles em diálise peritoneal e DRC 1 ou 2. Métodos: revisão retrospectiva dos prontuários de pacientes adultos internados, comparando aqueles com códigos de cobrança para "Hemodiálise" versus pacientes internados sem esses encargos, e uma coorte de pacientes em diálise peritoneal ambulatorial. Pacientes com DRC 3 ou 4 foram excluídos. Resultados: Cento e sessenta e sete prontuários foram revisados. Os intervalos de condução no ECG foram consistente- e estatisticamente mais longos entre os pacientes em hemodiálise (n = 88) vs. em diálise peritoneal (n = 22) e DRC estágios 1 e 2 (n = 57): PR (175 ± 35 vs 160 ± 44 vs 157 ± 22 msec) (p = 0,009); QRS (115 ± 32 vs. 111 ± 31 vs 91 ± 18 ms) (p = 0,001); QT (411 ± 71 vs. 403 ± 46 vs 374 ± 55 ms) (p = 0,006 ), QTc (487 ± 49 vs. 464 ± 38 vs 452 ± 52 ms) (p = 0,0001). A única anormalidade de condução significativamente diferente foi a prevalência de bloqueio do ramo esquerdo: 13,6% nos pacientes em HD, 5% em DP e 2% na DRC 1 e 2 (p = 0,03). Conclusão: Pelo que sabemos, este é o primeiro estudo a relatar que os intervalos de condução no ECG são significativamente maiores à medida que se progride das DRC Estágios 1 e 2, para DP, e para HD. Esses e outros dados corroboram a necessidade de estudos futuros para utilizar os tempos de condução no ECG para identificar pacientes em diálise que poderiam se beneficiar de avaliações cardíacas proativas e assim redução de risco.

Metabolic acidosis in hemodialysis: a neglected problem in Brazil / Acidose metabólica na hemodiálise: um problema menosprezado no Brasil

ABSTRACT Introduction: Metabolic acidosis is associated with the high mortality seen in hemodialysis patients. The panorama of metabolic acidosis in hemodialysis in Brazil is unclear since 1996 when the analysis of bicarbonate levels was no longer a compulsory exam. We aimed to establish the prevalence of metabolic acidosis in a hemodialysis population and analyze the factors associated with low bicarbonate levels. Methods: A cross-sectional study was carried out to assess the prevalence of metabolic acidosis in adults undergoing regular hemodialysis from January to April 2017, in four dialysis centers from Niteroi, Rio de Janeiro, Brazil, and surroundings. For blood gas analysis, samples of 2 mL were collected in heparinized syringes before a midweek dialysis session. Results: 384 patients with a mean age of 58.1 ± 15.8 years (54.5% men and 63.0%, non-white) were included. Approximately 30% had diabetes and 48%, hypertension. Nearly 88% used primary arteriovenous fistula as vascular access. The pre-dialysis mean serum tCO2 in the midweek session was 22.7 ± 3.0 mEq/L. The prevalence rate of serum bicarbonate below DOQI recommendation (22 mEq/L or higher) was 40.3%, and 6.5% had serum bicarbonate < 18 mEq/L. The dialyzer use count and the use of low-flux dialyzers were negatively associated whereas age and the standard Kt/V values were positively associated with the serum bicarbonate levels. Conclusion: The findings were in agreement with global data reported in previous studies. However, because the sample was relatively small and non-representative of the Brazilian population, a more comprehensive study, addressing national data is necessary to substantiate our findings.

RESUMO Introdução: A acidose metabólica está associada à elevada mortalidade observada em pacientes em hemodiálise. O panorama da acidose metabólica na hemodiálise no Brasil perdeu visibilidade em 1996, ano em que a análise dos níveis de bicarbonato deixou de ser obrigatória. Nosso objetivo foi estabelecer a prevalência da acidose metabólica em uma população em hemodiálise e analisar os fatores associados a baixos níveis de bicarbonato. Métodos: O presente estudo transversal avaliou a prevalência de acidose metabólica em adultos regularmente submetidos a hemodiálise de janeiro a abril de 2017, em quatro centros de diálise situados em Niterói e arredores no Estado do Rio de Janeiro. Para análise de gasometria, foram colhidas amostras de 2 mL em seringas heparinizadas antes das sessões de diálise do meio de semana. Resultados: Foram incluídos 384 pacientes com idade média de 58,1 ± 15,8 anos (54,5% homens; 63,0% não brancos). Aproximadamente 30% tinham diabetes e 48% apresentavam hipertensão. Cerca de 88% usavam fístula arteriovenosa primária como acesso vascular. A concentração sérica média pré-diálise de tCO2 na sessão do meio de semana foi de 22,7 ± 3,0 mEq/L. A taxa de prevalência de bicarbonato sérico abaixo do valor recomendado no DOQI (22 mEq/L ou superior) foi de 40,3%; 6,5% dos pacientes apresentaram bicarbonato sérico < 18 mEq/L. Os níveis séricos de bicarbonato apresentaram associações negativas com número de usos do dialisador e uso de dialisadores de baixo fluxo e associações positivas com idade e valores do Kt/V standard. Conclusão: Os resultados foram concordantes com dados globais relatados em estudos anteriores. Contudo, como a amostra era relativamente pequena e não representativa da população brasileira, são necessários estudos mais abrangentes que venham a abordar dados nacionais para consubstanciar nossos achados.