Toma de decisiones en hemodiálisis crónica: estudio cualitativo en adultos mayores / Decision making among older adults in hemodialysis. A qualitative assessment

Background: In Chile there are 22,310 people in Chronic Hemodialysis (CHD), 53% of them older adults (OA). Shared decision-making and advance directives (AD) are especially important in OA with end-stage chronic renal failure, since they have greater levels of disability, morbidity and mortality, raising doubts about the benefit of therapy. Aims: To understand the experience in decision making and explore ways to express AD, in OA in CHD. Material and Methods: A qualitative phenomenological study, performing 12 in-depth interviews to OA who had been at CHD for at least one year. Results: The analysis revealed four broad comprehensive categories, two related to participation in the decision to enter CHD, namely the experience of subjects as spectators and their lack of interest for decision support and two referred to the expression of AD, namely the difficulty in facing their own finitude and resistance to express AD. Conclusions: There is little participation of older adults in the decision about their admission to dialysis therapy, and once they enter the CHD program they are not prepared to discuss AD in general, nor an eventual suspension of dialysis in particular.

Índice C en médicos de dos centros hospitalarios chilenos según el test de competencia moral de Lind / Assessment of moral competence of physicians

Background: Moral competence (MC) in physicians is fundamental, given the increasing complexity of medicine. The "Moral Competence Test" (MCT © Lind) evaluates this feature and its indicator is the C Index (CI). Aim: To explore moral competence and its associated factors among physicians working in Chile. Material and Methods: The MCT was answered by 236 physicians from two medical centers who voluntarily participated in the study. Besides the test, participants completed an encrypted form giving information about gender, years in practice and post-graduate studies. Results: The average CI value of the participants was 20,9. Post-graduate studies had a significant positive influence on CI. There was a significant decrease in CI, between 16 and 20 years of professional exercise. Gender and the area of post-graduate studies did not have a significant influence. Conclusions: The studied physicians showed a wide range of CI which was positively affected by the postgraduate studies performed. The years of professional practice had a negative influence. Expanding training opportunities during professional practice could have a positive effect on CM as measured by CI.

Puntaje predictivo de emergencias médicas en un servicio médico quirúrgico, usando variables clínicas y los diagnósticos de ingreso / A score to predict medical emergencies in hospitalized patients

Background: The medical alert system (MAS) was created for the timely handling of clinical decompensations, experienced by patients hospitalized at the Medical Surgical Service (MSS) in a private clinic. It is activated by the nurse when hemodynamic, respiratory, neurological, infectious or metabolic alterations appear, when a patient falls or complains of pain. A physician assesses the patient and decides further therapy. Aim: To analyze the clinical and demographic characteristics of patients who activated or not the MAS and develop a score to identify patients who will potentially activate MAS. Material and Methods: Data from 13,933 patients discharged from the clinic in a period of one year was analyzed. Results: MAS was activated by 472 patients (3.4%). Twenty two of these patients died during hospital stay compared to 68 patients who did not activate the alert (0.5%, p < 0.01). The predictive score developed considered age, diagnosis (based on the tenth international classification of diseases) and whether the patient was medical or surgical. The score ranges from 0 to 9 and a cutoff ≥ 6 provides a sensitivity and specificity of 37 and 81% respectively and a positive likelihood ratio (LR+) of 1.9 to predict the activation of MAS. The same cutoff value predicts death with a sensitivity and specificity of 80% and a negative predictive value of 99.8%. Conclusions: This score may be useful to identify hospitalized patients who may have complications during their hospital stay.

Conflictos de intereses en nefrología / Conflicts of interest in nephrology

Since doctors disposed of effective tools to serve their patients, they had to worry about the proper management of available resources and how to deal with the relationship with the industry that provides such resources. In this relation­ship, health professionals may be involved in conflicts of interest that they need to acknowledge and learn how to handle. This article discusses the conflicts of interest in nephrology. Its objectives are to identify those areas where such conflicts could occur; to help to solve them, always considering the best interest of patients; and to help health workers to keep in mind that they have to preserve their autonomy and professional integrity. Conflicts of interest of professionals in the renal area and related scientific societies, with the industry producing equipment, supplies and drugs are reviewed. Dichotomy, payment for referral, self-referral of patients and incentives for cost control are analyzed. Finally, recommendations to help preserve a good practice in nephrology are made.

Problemas ético-clínicos en hemodiálisis crónica: percepción de médicos y enfermeras / Ethical issues perceived by health care professionals working in chronic hemodialysis centers

Background: Clinical teams working at chronic hemodialysis centers (CHC) frequently have to face ethical problems, but there is no systematic approach to deal with them. Aim: To study the ethical problems perceived by health professionals at CHC. Material and Methods: Eighty randomly selected physicians and 139 nurses from 23 CHC, answered a structured questionnaire, devised by the research team. Results: Twenty-six percent of respondents had postgraduate studies in clinical ethics. The ethical problems mentioned by respondents were therapeutic disproportion in 66.7%, lack of communication between patients, their families and the clinical team in 25.9%, personal conflicts of interests related with hemodialysis prescription in 14.6% and conflicts of interests of other members of the clinical team in 30.6%. The percentage of respondents that experienced not starting or discontinuing hemodialysis treatment due to decision of patients’ relatives was 86.8%. Only 45.2% of health professionals had the opportunity to take part in decision-making meetings. Eighty seven percent of respondents supported the use of advanced directives in the event of a cardio respiratory arrest during treatment. Conclusions: To improve the approach to ethical problems in CHC, it is necessary to improve training in clinical ethics, promote an effective dialogue between the patients, their families and health professionals, and follow their advance directives in case of cardiac arrest during treatment.

Incidencia de la injuria renal aguda en unidad de paciente crítico y su mortalidad a 30 días y un año / Incidence and consequences of acute kidney injury among patients admitted to critical care units

Background: Acute Kidney Injury (AKI) increases morbidity, mortality and hospital stay in critical patients units (CPU). Aim: To determine the incidence and mortality of AKI in CPU. Material and Methods: Review of electronic medical records of 1,769 patients aged 61 ± 20 years (47% males) discharged from a CPU during one year. Acute Kidney Injury diagnosis and severity was established using the Acute Kidney Injury Network (AKIN) criteria. Results: A history of hypertension and Diabetes Mellitus was present in 44 and 22% of patients, respectively. APACHE II and SOFA scores were 14.6 ± 6.8 and 3.6 ± 2.1 respectively. AKI incidence was 28.9% (stage I, 16.7%, stage II, 5.3% and stage III, 6.9%). Mortality during the first 30 days and during the first year was 8.1 and 20.0% respectively. Patients with stage III AKI had the highest mortality (23.8 and 40.2% at 30 days and one year respectively). Compared with patients without AKI, the Odds ratio for mortality at 30 days and one year of patients with AKI stage III was 3.7 and 2.5, respectively. Conclusions: Thirty percent of patients admitted to UPC develop an AKI, which influences 30 days and one year mortality.

Recomendaciones del Comité de Ética de la Sociedad Chilena de Nefrología para el manejo de los problemas ético-clínicos de pacientes adultos con enfermedad renal crónica terminal / Recommendations of the Ethics Committee of the Chilean Society of Nephrology for the management of ethical problems in adult end stage renal disease patients

There are different approaches to treat patients with End Stage Renal Disease (ESRD): hemodialysis, peritoneal dialysis, renal transplantation and conservative medical management. The choice of the best therapy for each patient, needs both clinical and ethical skills. The Ethics Committee of the Chilean Society of Nephrology has elaborated recommendations to help health workers to deal with the ethical and clinical problems related to patients suffering ESRD. Its goal is to guide, at a national level, the effective use of minimal standards in the treatment and care of patients with ESRD, including appropriate care and information for patients, therapy selection, management of difficult cases and potential conflicts.

Embarazos exitosos en hemodiálisis crónica: experiencia de un único centro / Pregnancy during dialysis: Experience in six patients

Background: The frequency of pregnancies during dialysis is increasing. This condition requires changes in the dialysis schedule and nutritional approach. Aim: To report the experience in six patients with terminal kidney disease who became pregnant. Material and Methods: Retrospective review of medical records of women with terminal kidney disease in dialysis who became pregnant in a period of 27 years. Results: We recorded six successful pregnancies among women in hemodialysis treatment aged 32 ± 4 years. The mean dialysis-time per week was 19.5 ± 2.7 hours and Kt/V was 1.55 ± 0.17. The mean systolic blood pressure was 130 ± 13.3 mmHg. The mean packed cell volume of the group increased from 22.7% during pre-gestational stage to 30.2% during third trimester of pregnancy. All patients received an intensive treatment for anemia. The most common symptom of pregnancy was hyperemesis. The mean gestational age (GA) at diagnosis was 13.4 ± 4.7 weeks. All patients had preterm deliveries at a GA of 33 ± 1.7 weeks, and 66% of offspring were appropriate for gestational age. Conclusions: A multidisciplinary approach allows high rate of successful pregnancies during hemodialysis.

Daño arterial asociado a la enfermedad renal crónica: evaluación mediante técnicas de laboratorio no invasivo en pacientes hemodializados / Assesment of arterial damage by noninvasive peripheral arterial tonometry in non-diabetic hemodialysis patients

Background: Hemodialysis patients (HD) display high rates of cardiac disease and mortality. The cardiovascular morbidity and mortality of HD patients is attributable in a significant proportion to endothelial dysfunction, arterial stiffness, and vascular calcifications. Aim: To measure vascular reactivity in HD subjects and compare them with healthy volunteers. Material and Methods: Forty eight non diabetic patients aged 58 ± 4.6 years (29 males) on hemodialysis for a mean lapse of 4.8 years were studied. Arterial stiffness was measured in the radial artery. Pulse wave velocity was measured by noninvasive peripheral arterial tonometry in carotid and femoral arteries. Endothelial function was assessed, measuring reactive hyperemia response after a 5 min period of ischemia. As a control, all values were also measured in age and gender-matched healthy volunteers. Results: Arterial stiffness was significantly higher in HD patients than controls (23.9 ± 3.3 and 18.4 ± 3.4% respectively, p < 0.05). HD subjects had an increased pulse wave velocity (10.0 ± 0.8 and 7.6 ± 0.9 m/s respectively, p < 0.05). A reduction in the change in pulse amplitude pressure, as a measure of arterial dysfunction, was only observed in male patients (1.7± 0.4 and2.7 ± 0.4 respectively p < 0.01). Conclusions: Noninvasive assessment of peripheral vascular function may be useful for the identification of patients at risk for late cardiac events.

Evolución del compromiso cardiovascular de pacientes insuficientes renales, en hemodiálisis, sin bloqueo del eje renina-angiotensina / Cardiovascular assessment of non diabetic patients on hemodialysis

Background: Diabetes mellitus is an important risk factor for cardiovascular complications among patients on hemodialysis. However, the incidence of these complications among non diabetic patients on hemodialysis is not well known. Aim: To assess the incidence of cardiovascular complications in non diabetic patients on hemodialysis. Patients and methods: Seventy five non diabetic patients aged 55.6 ± 17 years (48 males), receiving hemodialysis three times a week were evaluated with laboratory tests, echocardiogram anda carotid ultrasound. In 26 patients, interleukin 6, tumor necrosis factor alpha, and intercellular adhesión molecule (ICAM-1) were also measured. Patients were followed during two years. Results: The mean lapse of dialysis therapy was 6.5 ±5 years. The main cause of renal failure was hypertension. Sixty two percent had systolic hypertension, 86 percent had concentric left ventricular hypertrophy, 43 percent had atrial dilatation and 60 percent had calcifications in the thoracic aorta. Compared with normal controls, patients had higher levels of interleukin 6, tumor necrosis factor alpha and ICAM-1. Carotid media thickness was also higher and increased in the two years of follow up. No correlations were found between ventricular hypertrophy and dialysis lapse, packed red cell volume, calcium phosphorus product, parathormone levels or median arterial pressure. No cardiovascular events were recorded during the follow up period. Conclusions: Non diabetic patients on chronic hemodialysis have a high frequency of ventricular hypertrophy, carotid media thickening, aortic calcifications and an increase in proinflammatory cytokines.

Disección espontánea de la arteria renal e infarto renal: dos casos clínicos / Spontaneous dissection of the renal artery ano kidney infarction: report of two cases

We report two previously healthy males aged 33 and 37 years, presenting with severe pain in the right and left part of the abdomen, respectively. An abdominal CT sean showed in both a kidney infarction. An angio-CAT sean showed changes compatible with a fibromuscular dysplasia in the renal arterial wall. An angiography showed an intimal tear or complex dissection flap in both cases. Both had a satisfactory evolution with conservative treatment. The relationship between fibromuscular dysplasia and spontaneous dissection of the renal artery is discussed.