Calidad de vida percibida y adherencia al tratamiento en pacientes con insuficiencia renal crónica terminal / Perceived quality of life and adherence to treatment in patients with end-stage chronic renal disease / Qualidade de vida percebida e adesão ao tratamento em pacientes com doença renal crônica em estágio terminal

RESUMEN Introducción: La insuficiencia renal crónica terminal constituye uno de los problemas de salud más complejos por las afectaciones que provoca a la calidad de vida de los pacientes y por las dificultades que entraña la adherencia del paciente al tratamiento. Objetivo: Identificar la relación entre la calidad de vida percibida y la adherencia al tratamiento de los pacientes portadores de insuficiencia renal crónica terminal que reciben hemodiálisis. Método: Estudio de tipo correlacional realizado en el servicio de Hemodiálisis del Hospital General Docente "Juan B. Viñas González" de Palma Soriano, Santiago de Cuba. Del universo de 32 pacientes se trabajó con la población constituida por 16 pacientes que cumplieron con los criterios de inclusión/exclusión. Las técnicas utilizadas fueron: cuestionario de calidad de vida de la OMS, revisión de documentos, entrevistas y la observación. Se realizó análisis estadístico descriptivo (análisis de frecuencias) y se aplicó el método no paramétrico de correlación de Spearman. Resultados: Más de la mitad (56,25 %) de la población reflejó una calidad de vida percibida regular, el 25 % buena y el 18,75 % mala. La dimensión de salud física se mostró dentro de las más afectadas, observándose una valoración negativa con respecto a la enfermedad, pues más del 85 % de los encuestados la consideró como grave o muy grave. Se apreciaron afectaciones al sueño, donde más del 60 % de los pacientes se sintió insatisfecho con este aspecto. Los síntomas de la enfermedad son valorados, por la mayoría (81,25 %) como severos o muy severos. Conclusiones: Los pacientes poseen adherencia media al tratamiento y una calidad de vida percibida regular, y existe correlación fuerte y directa entre la adherencia al tratamiento y la calidad de vida percibida.

ABSTRACT Introduction: The end-stage chronic renal disease, due to how it affects the patient´s quality of life and the difficulties involved in the adherence of patient to treatment, is one of the most complex health problems. Objective: To identify the relationship between perceived quality of life and adherence to treatment in patients with end-stage chronic renal disease receiving hemodialysis. Method: A correlative study was conducted in the hemodialysis service room at the Hospital General Docente "Juan B. Viñas González" in Palma Soriano, Santiago de Cuba. The universe studied included 32 patients and 16 (met inclusion/exclusion criteria) were selected to work with. The techniques used were: World Health Organization quality of life questionnaire, document review, interviews and observation. A descriptive statistical analysis was performed (frequency analysis) and the nonparametric method applied was the Spearman's correlation coefficient using the SPSS 19.0 data processing program. Results: More than half of the population (56.25%) reported a fair quality of life, good (25%), and bad (18.75%). The physical health dimension was one of the most affected and it was found a negative assess of the disease in which more than 85% of those polled considered it as serious or very serious. Some sleep disorders was found and more than 60% of patients were unsatisfied related this issue. Most of the patients (81.25%) characterized the disease symptoms as severe or very severe. Conclusions: Patients studied had an adherence to treatment in a medium level and a perceived fair quality of life. There is also a correlation between the patient adherences to treatment and perceived quality of life.

RESUMO Introdução: A insuficiência renal crônica terminal constitui um dos problemas de saúde mais complexos pelos efeitos que causa na qualidade de vida dos pacientes e pelas dificuldades que a adesão do paciente ao tratamento acarreta. Objetivo: Identificar a relação entre a percepção de qualidade de vida e a adesão ao tratamento em pacientes com doença renal terminal em hemodiálise. Método: Estudo do tipo correlacional realizado no serviço de Hemodiálise do Hospital Geral de Ensino "Juan B. Viñas González" em Palma Soriano, Santiago de Cuba. Do universo de 32 pacientes, trabalhamos com a população composta por 16 pacientes que atenderam aos critérios de inclusão / exclusão. As técnicas utilizadas foram: questionário de qualidade de vida da Organização Mundial da Saúde, revisão documental, entrevistas e observação. Foi realizada análise estatística descritiva (análise de frequência) e aplicado o método não paramétrico. Resultados: Mais da metade (56,25%) da população apresentou percepção de qualidade de vida regular, 25% boa e 18,75% ruim. A dimensão saúde física esteve entre as mais afetadas, com avaliação negativa em relação à doença, uma vez que mais de 85% dos inquiridos a consideraram grave ou muito grave. Além disso, foram notados distúrbios do sono, onde mais de 60% dos pacientes se sentiram insatisfeitos com esse aspecto. Os sintomas da doença são avaliados, pela maioria (81,25%), como graves ou muito graves. Conclusões: Os pacientes apresentam média de adesão ao tratamento e percepção de qualidade de vida regular, havendo forte e direta correlação entre adesão ao tratamento e percepção de qualidade de vida.

Pure red cell aplasia and anti-erythropoietin antibodies in patients on hemodialysis: a report of two cases and a literature review / Aplasia pura de células vermelhas e anticorpo antieritropoietina em pacientes de hemodiálise: relato de dois casos e revisão da literatura

ABSTRACT Introduction: Anemia is a frequent multifactorial complication of CKD seen in patients on dialysis derived mainly from impaired erythropoietin (EPO) production. A less common cause of anemia in individuals with CKD is pure red cell aplasia (PRCA) secondary to the production of anti-EPO antibodies. Objective: This paper aimed two describe two cases of PRCA secondary to the production of anti-EPO antibodies including choice of treatment, patient progression, and a literature review. Materials: This study included the cases of two patients with CKD on hemodialysis with severe anemia in need of specific investigation and management. Results: Patient 1 with CKD secondary to hypertension treated with EPO for 7 months showed persistent decreases in hemoglobin (Hb) levels despite the subcutaneous administration of increasing doses of EPO; the patient required recurring blood transfusions. Workup and imaging tests were negative for the main causes of anemia in individuals with CKD on dialysis. Patient 2 with CKD secondary to adult polycystic kidney disease had been taking EPO for 2 years. The patient developed severe abrupt anemia the month he was started on HD, and required recurring transfusions to treat the symptoms of anemia. Workup and imaging findings were inconclusive. Specific laboratory tests confirmed the patients had anti-EPO antibodies. After six months of immunosuppressant therapy (corticosteroids + cyclosporine) the patients were stable with Hb > 9.0 g/dl. Conclusion: PRCA is a rare condition among patients on dialysis treated with rhEPO and should be considered as a possible cause of refractory anemia. Treating patients with PRCA may be challenging, since the specific management and diagnostic procedures needed in this condition are not always readily available.

RESUMO Introdução: Anemia é complicação frequente da Doença Renal Crônica (DRC) em pacientes dialíticos. Apresenta caráter multifatorial principalmente pela insuficiente produção de eritropoietina (EPO). Situação rara causadora de anemia na DRC é Aplasia Pura de Células Vermelhas (APCV), em decorrência da produção de anticorpos anti-EPO. Objetivo: Descrever 2 casos de APCV com formação de anticorpos anti-EPO, sua abordagem clínica, evolução e revisão de literatura. Métodos: Dois pacientes em hemodiálise que desenvolveram anemia grave, necessitando investigação e manejo específico. Resultados: Paciente nº 1: feminina, 75 anos, DRC secundária à hipertensão arterial. Após 7 meses com EPO desenvolveu queda persistente em valores de hemoglobina (Hb) mesmo com incremento em doses EPO SC, necessitando transfusões de sangue recorrentes. Extensa investigação laboratorial e de imagem resultou negativa para principais causas de anemia. Paciente nº 2: masculino, 66 anos, DRC secundária à DRPA, há 2 anos em uso de EPO. No mês de entrada em HD desenvolveu anemia severa, também exigindo transfusões recorrentes para tratamento da anemia sintomática. Extensa investigação laboratorial e por imagem, sem chegar a uma conclusão definitiva. Em ambos os casos a presença de anticorpos anti-EPO foi confirmada por exames laboratoriais específicos. Terapia imunossupressora resultou em estabilização do quadro e Hb > 9,0 g/dl em ambos os pacientes, 6 meses após início do tratamento. Conclusão: APCV é condição rara entre pacientes dialíticos que recebem EPOHuR e deve ser lembrada como causa de anemia refratária. Seu manejo específico e diagnóstico laboratorial nem sempre acessível, tornando desafiadora a condução dos casos para o nefrologista.

Salvianolic acid A alleviates the renal damage in rats with chronic renal failure

Abstract Purpose: To investigate the protective effects of salvianolic acid A (SAA) on renal damage in rats with chronic renal failure (CRF). Methods: The five-sixth nephrectomy model of CRF was successfully established in group CRF (10 rats) and group CRF+SAA (10 rats). Ten rats were selected as sham-operated group (group S), in which only the capsules of both kidneys were removed. The rats in group CRF+SAA were intragastrically administrated with 10 mg/kg SAA for 8 weeks. The blood urine nitrogen (BUN), urine creatinine (Ucr), creatinine clearance rate (Ccr), and serum uperoxide dismutase (SOD) and malondialdehyde (MDA) were tested. The expressions of transforming growth factor-β1 (TGF-β1), bone morphogenetic protein 7 (BMP-7) and Smad6 protein in renal tissue were determined. Results: After treatment, compared with group CRF, in group CRF+SAA the BUN, Scr, serum MDA and kidney/body weight ratio were decreased, the Ccr and serum SOD were increased, the TGF-β1 protein expression level in renal tissue was decreased, and the BMP-7 and Smad6 protein levels were increased (all P < 0.05). Conclusion: SAA can alleviate the renal damage in CRF rats through anti-oxidant stress, down-regulation of TGF-β1 signaling pathway and up-regulation of BMP-7/Smad6 signaling pathway.

Adrenomedulina en la fisiología y fisiopatología renales / Adrenomedullin in the kidney: physiology and pathophysiology

La adrenomedulina (ADM), péptido vasodilatador de 52 aminoácidos, ubícuo, posee múltiples efectos fisiológicos que contribuyen a respuestas homeostáticas. Se encuentra en concentraciones importantes en la glándula suprarrenal, el pulmón, el sistema cardiovascular y el renal. Ejerce acciones biológicas a través de sus receptores AM1 y AM2, heterodímeros constituidos por el receptor semejante al receptor de calcitonina (CLR) y proteínas modificadoras de la actividad del receptor (RAMPs), CLR/RAMP2 y CLR/RAMP3, respectivamente. La principal vía de señalización es la adenilato ciclasa/AMPc en patologías cardiovasculares y renales, así como en la sepsis. Los niveles plasmáticos de ADM se elevan proporcionalmente con el incremento de la presión sanguínea y con el grado de daño renal, en pacientes con hipertensión arterial; así mismo, dichos niveles se correlacionan con el grado de hipertrofia cardíaca y arterial. La ADM tiene efectos renales, tubulares, ya que tiene acción diurética y natriurética; posee efectos vasodilatadores que producen aumento de la tasa de filtración glomerular y del flujo sanguíneo renal. Este péptido inhibe la proliferación y la generación de radicales libres en células mesangiales; actúa inhibiendo la secreción de aldosterona en la zona glomerulosa y de endotelina-1 en células musculares lisas vasculares. Se ha propuesto como marcador de riesgo en diversas patologías, especialmente en la insuficiencia renal crónica; en esta patología, que cursa con hipertrofia compensadora de los glomérulos y proliferación del mesangio, la administración de ADM disminuye los niveles de proteinuria, lo que sugiere que además de un importante rol modulador en la presión arterial, pudiera ser una opción terapéutica para la insuficiencia renal crónica.

Adrenomedullin (AM) is a potent vasodilatory 52-aminoacid peptide hormone, ubiquitous with multiple physiological effects which contribute to homeostatic responses. Significantly, it is distributed in the adrenal gland, lung, cardiovascular and renal system. The biological effects of AM are directly mediated by specific receptors as heterodimers composed of the calcitonin-receptor-like receptor (CLR) and one of two receptor activity modifying proteins (RAMP2 or RAMP3). The CLR/RAMP2 (AM1 receptor) is more highly AM-specific than The CLR/RAMP3 (AM2 receptor). Plasma levels of AM are elevated proportionately to the increase in blood pressure and degree of renal damage in patients with hypertension; likewise, these levels are correlated with the degree of heart and arterial hypertrophy. AM has renal vasodilatory, natriuretic and diuretic actions; increased glomerular filtration rate and renal blood flow. AM inhibits proliferation and reactive oxygen species generation in mesangial cells; also inhibits aldosterone secretion in the zona glomerulosa and endothelin-1 in vascular smooth muscle cells. Therefore, it is proposed as a new marker in various diseases, especially chronic renal failure. This disease presents compensatory hypertrophy of the glomeruli and mesangial proliferation, administration of AM reduces the levels of proteinuria, suggesting that AM has an important modulator role in blood pressure and could be a therapeutic option for chronic renal failure.

Cyclosporine versus tacrolimus: cost-effectiveness analysis for renal transplantation in Brazil / Análise de custo-efetividade: ciclosporina versus tacrolimo para transplante renal no Brasil

OBJECTIVE To analyze the cost-effectiveness of treatment regimens with cyclosporine or tacrolimus, five years after renal transplantation. METHODS This cost-effectiveness analysis was based on historical cohort data obtained between 2000 and 2004 and involved 2,022 patients treated with cyclosporine or tacrolimus, matched 1:1 for gender, age, and type and year of transplantation. Graft survival and the direct costs of medical care obtained from the National Health System (SUS) databases were used as outcome results. RESULTS Most of the patients were women, with a mean age of 36.6 years. The most frequent diagnosis of chronic renal failure was glomerulonephritis/nephritis (27.7%). In five years, the tacrolimus group had an average life expectancy gain of 3.96 years at an annual cost of R$78,360.57 compared with the cyclosporine group with a gain of 4.05 years and an annual cost of R$61,350.44. CONCLUSIONS After matching, the study indicated better survival of patients treated with regimens using tacrolimus. However, regimens containing cyclosporine were more cost-effective. .

OBJETIVO Analisar custo-efetividade de regimes terapêuticos com ciclosporina ou tacrolimo cinco anos após transplante renal. MÉTODOS Análise de custo-efetividade com base em dados de coorte histórica 2000-2004, com 2.022 pacientes tratados com ciclosporina ou tacrolimo e pareados 1:1 segundo sexo, idade, tipo e ano de transplante. A sobrevida do enxerto e os custos diretos de cuidados médicos a partir das bases de dados do Sistema Único de Saúde foram utilizados como medida de resultado. RESULTADOS A maioria dos pacientes era do sexo feminino e média de idade de 36,6 anos. O diagnóstico mais frequente de insuficiência renal crônica foi a glomerulonefrite/nefrite (27,7%). Em cinco anos, o grupo tacrolimo obteve uma expectativa de vida média de 3,96 anos de vida ganhos ao custo anual de R$78.360,57 ante 4,05 anos de vida ganhos e de R$61.350,44 para ciclosporina. CONCLUSÕES Após o pareamento, o estudo não mostrou melhor sobrevida dos pacientes com regimes que usam tacrolimo. Além disso, regimes contendo ciclosporina foram mais custo-efetivos. .

Toxocara cati (Nematoda: Ascarididae) in Didelphis albiventris (Marsupialia: Didelphidae) from Brazil: a case of pseudoparasitism / Toxocara cati (Nematoda: Ascarididae) em Didelphis albiventris (Marsupialia: Didelphidae) do Brasil: um caso de pseudoparasitismo

Eggs of Toxocara cati were found in the feces of Didelphis albiventris from a peridomestic urban environment in Brazil. Negative fecal tests following short-term captivity of the opossums, as well as the absence of ascaridids during necropsy, suggest the occurrence of pseudoparasitism. Implications of the findings for the epidemiology of toxocariasis are discussed.

Ovos de Toxocara cati foram encontrados nas fezes de Didelphis albiventris oriundos de um ambiente peridomiciliar urbano no Brasil. A negatividade dos exames de fezes após um curto período de cativeiro dos gambás e a ausência de nematódeos ascaridídeos durante a necropsia sugerem a ocorrência de pseudoparasitismo. As implicações dos achados para a epidemiologia da toxocarose são discutidas.

Adherence to drug therapy in kidney disease

Non-adherence to drug therapy has not been extensively studied in patients with chronic kidney disease (CKD). The objective of the present study was to identify determinants of non-adherence to drug therapy in patients with CKD, not on dialysis. A prospective cohort study involving 149 patients was conducted over a period of 12 months. Adherence to drug therapy was evaluated by the self-report method at baseline and at 12 months. Patients who knew the type of drug(s) and the respective number of prescribed pills in use at the visit preceding the interview were considered to be adherent. Patients with cognitive decline were assessed by interviewing their caregivers. Mean patient age was 51 ± 16.7 years. Male patients predominated (60.4 percent). Univariate analysis performed at baseline showed that non-adherence was associated with older age, more pills taken per day, worse renal function, presence of coronary artery disease, and reliance on caregivers for the administration of their medications. In multivariate analysis, the factors that were significantly associated with non-adherence were daily use of more than 5 pills and drug administration by a caregiver. Longitudinal evaluation showed an increase in non-adherence over time. Medication non-adherence was lower (17.4 percent) at the baseline period of the study than after 1 year of the study (26.8 percent). Compared to the baseline period, the percentage of adherent patients who became non-adherent (22 percent) was lower than the percentage of non-adherent patients who became adherent (50 percent). In CKD patients not on dialysis, non-adherence was significantly associated with the number of pills taken per day and drug administration by third parties. Adherence is more frequent than non-adherence over time.

Nephroprotective role of salacia chinensis in diabetic CKD patients: A pilot study.

Background: Present study aimed to study effect of Salacia Chinensis, a herbal drug, on stabilization of renal functions, and markers of endothelial dysfunction in diabetic chronic kidney disease (CKD) patients. Materials and Methods: 30 stable diabetic CKD patients were randomized into 2 groups; group A and B of 15 patients each. Group A was given trial drug Salacia chinensis 1000 mg twice-daily while group B received placebo. Measures of renal function: Serum creatinine and creatinine clearance; markers of endothelial dysfunction: Interleukin-6 and serum Homocysteine, and lipid profile were measured at baseline and during follow-up period of 6 months. Results : There was stabilization of renal function as measured by serum creatinine and creatinine clearance in patients who received Salacia Chinensis compared to placebo (P value < 0.05), suggesting that Salacia chinensis may retard the progression of chronic kidney disease. Similarly, there was significant decline in both serum homocysteine and IL-6 levels. [P value < 0.05 for both]. Conclusion: This pilot study showed a promising role for Salacia chinensis as a renoprotective drug, but further prospective studies involving large number of patients are needed to confirm this and also to delineate possible mechanisms.

Determinantes da não-adesão medicamentosa nos pacientes em hemodiálise / Determinants of medication noncompliance in patients on hemodialysis

Introdução: Apesar de contribuir para a morbidade e mortalidade dos pacientes em hemodiálise, a não-adesão medicamentosa é um aspecto pouco estudado nesses pacientes. Objetivo: Avaliar as causas de não-adesão medicamentosa nos pacientes em programa de hemodiálise crônica. Material e Métodos: Uma coorte de 65 pacientes respondeu um questionário composto de 35 perguntas relacionadas com o uso de suas medicações. Esse questionário foi desenvolvido em nossa unidade para ser aplicado especificamente entre os pacientes em diálise e procurou avaliar diversos aspectos relacionados às medicações de uso ambulatorial. Paralelamente, os pacientes foram estratificados em classes econômicas e avaliados quanto ao perfil de depressão. Resultados: O estudo mostra que a prevalência da não-adesão é alta entre os pacientes em diálise. As causas para este problema são múltiplas, envolvendo desde o elevado número de medicamentos, de comprimidos e de tomadas diárias, até a disponibilidade e acesso à medicação. Também, o desconhecimento da ação terapêutica da droga, os efeitos colaterais e a falha no preenchimento das expectativas de saúde do paciente foram causas importantes de não-adesão. Um número elevado de pacientes se declarou desestimulado para o uso regular da medicação; entretanto, o perfil depressivo e econômico não contribuiu para a não-adesão. Conclusão: Nosso estudo mostra que a etiologia da não-adesão medicamentosa de pacientes em hemodiálise é multifatorial, exigindo uma mudança na abordagem dessa condição pela equipe médica com a necessidade de um enfoque multidisciplinar associado à constante supervisão e orientação do paciente.

Introduction: Medication noncompliance contributes to morbidity and mortality of hemodialysis patients; however, there are few studies in this area. Objective: To evaluate the causes of medication noncompliance in patients undergoing hemodialysis. Methods: A cohort of 65 patients answered a questionnaire with 35 questions. This questionnaire was developed to be applied in hemodialysis patients to evaluate several aspects related to medication use. At the same time, patients were stratified by socioeconomic situation and the presence of depression. Results: The results showed a high prevalence of medication noncompliance in hemodialysis patients. Causes for noncompliance were multiple and involved the high number of drugs, pills and dose frequency, in addition to the availability and access to medication. Also, the low levels of knowledge about medications, side effects and failure to fulfill patient health beliefs were identified as causes for noncompliance. Several patients expressed a lack of motivation to take the medication; however, socioeconomic situation and the presence of depression did not influence noncompliance. Conclusion: Our study shows that the cause of medication noncompliance in hemodialysis patients is multifactorial. Consequently, a change in medical team approach is required to include a multidisciplinary focus associated with a constant supervision and guidance of these patients.

Reduction of kidney damage by supplementation of vitamins C and E in rats with deoxycorticosterone-salt-induced hypertension

We assessed whether cosupplementation of vitamins C and E has additive beneficial effects on reducing the kidney damage and attenuation of the arterial pressure elevation compared to administration of either vitamin C or vitamin E alone in deoxycorticosterone acetate-salt-induced hypertension. Forty rats were divided into 4 study groups and 1 sham-operated group. Unilateral nephrectomy was carried out in the study groups and hypertension was induced by deoxycorticosterone injection and 1% sodium chloride and 0.2% potassium chloride added to the drinking water. Vitamins C and E [200 mg/kg/day] or combination of them were administered with DOCA-salt for 4 weeks in 3 study groups. The effects of DOCA and salt and treatment with vitamins were compared in terms of blood pressure, urinary protein excretion, antioxidant activity of the kidneys, and renal histological changes. Four weeks of supplementations of vitamins C, vitamin E, and both in the DOCA-salt-treated rats had comparable significant effects in decreasing systolic blood pressure. Urinary protein excretion and histological damage did not significantly change with the combination therapy of vitamins C and E compared to the vitamin C or E alone. The renal levels of glutathione and ferric reducing/antioxidant power in combination therapy group were similar to the two other treatment groups and were significantly higher than non-treated group. Co-administration of vitamin C and E does not have an additive beneficial effect on reducing the kidney damage and hypertension compared to either vitamin C or E alone in DOCA-salt-induced hypertension

Different doses of oral folic acid for homocysteine-lowering therapy in patients on hemodialysis a randomized controlled trial

We compared the effect of higher and lower doses of folic acid compared to our routine daily dose on plasma homocysteine levels, in our hemodialysis patients. Eighty patients on hemodialysis receiving oral folic acid, 10 mg/d, were randomized to receive folic acid at either doses of 5 mg/d [group 1] or 15 mg/d [group 2] for 2 months. Plasma levels of total homocysteine were measured before and after the study period. Hyperhomocysteinemia was seen in 75 patients [93.8%] before, and in 37 patients of group 1 [92.5%] and 39 of group 2 [97.5%] after the study period. In group 1, a nonsignificant decrease occurred in plasma homocysteine level [29.67 +/- 12.26 micro mol/L to 27.78 +/- 9.94 micro mol/L, P = .30], while in group 2, there was a significant decrease in homocysteine level [32.40 +/- 9.76 micro mol/L to 29.58 +/- 9.62 micro mol/L, P = .01]. Changes in homocysteine level correlated with its baseline level [r = -0.42, P < .001]. In both groups, significant reductions in homocysteine level were seen mostly in those patients with high baseline homocysteines. Routine folic acid supplementation of 10 mg/d could not normalize plasma homocysteine levels in most of our patients. Increasing folic acid dose made a statistically significant but clinically trivial decrease in homocysteine levels, and could not normalize homocysteine level in most patients. Patients with a higher baseline homocysteine level achieved a greater reduction, which may be explained by primary noncompliance of some patient. Further investigation of folic acid dosage is suggested

Prescrição de quelantes de fósforo e calcitriol para pacientes em hemodiálise crônica / Prescription of phosphorus binders and calcitriol for chronic hemodialysis patients

OBJETIVO: Descrever a frequência de prescrição de quelantes de fósforo (QF) e calcitriol em pacientes sob hemodiálise (HD) crônica em Salvador, Brasil, e avaliar se o tratamento está de acordo com recomendações do Kidney Disease Outcomes Quality Initiative (K/DOQI). MÉTODOS: Corte transversal de dados da linha de base do Estudo Prospectivo do Prognóstico de Pacientes Tratados Cronicamente por Hemodiálise (PROHEMO). Foi realizada descrição da frequência de prescrição de QF e calcitriol conforme as concentrações de indicadores laboratoriais do metabolismo mineral, comparando com recomendações do K/DOQI. RESULTADOS: Sevelamer isoladamente (i.e., não combinado com outro QF) foi prescrito para 45,4 por cento dos pacientes, carbonato de cálcio (CaCO3) isoladamente para 26,5 por cento, sevelamer combinado com CaCO3 para 2,1 por cento e acetato de cálcio para 5,2 por cento. Prescrição de QF foi observada para 53 por cento dos pacientes com fósforo <3,5 mg/dL e 40 por cento com fósforo <3,0 mg/dL. Em desacordo com K/DOQI, prescrição de calcitriol foi detectada para 19 por cento dos pacientes com PTH<150 pg/mL e ausência da prescrição para aproximadamente 35,4 por cento com PTH>300 pg/dL combinado com fósforo menor ou igual a 5,5 mg/dL, cálcio menor ou igual a 9,5 mg/dL e produto cálcio e fósforo (CaxP)<55 mg2/dL2. Neste último grupo, 38 por cento tiveram prescrição de sevelamer sem outro QF. CONCLUSÃO: Os resultados mostram um elevado percentual de prescrição de sevelamer em pacientes em HD de manutenção em uma cidade brasileira, apesar do alto custo deste medicamento e ausência de contraindicação para QF à base de cálcio. Os resultados em pacientes com PTH<150 pg/mL e com PTH>300 pg/mL combinado com determinadas concentrações de cálcio, fósforo e CaxP indicam também a necessidade de avaliar as práticas de uso de QF e calcitriol.

OBJECTIVE: To describe the frequency of prescription of phosphate binders (PB) and calcitriol for patients on chronic hemodialysis in Salvador, Brazil, and to assess whether treatment is in agreement with recommendations of the Kidney Disease Outcomes Quality Initiative (K/DOQI). METHODS: Cross section of baseline data of the PROHEMO study. The frequency of prescription of PB and calcitriol according to laboratory indicators of mineral metabolism was compared with K/DOQI recommendations. RESULTS: Sevelamer alone (i.e., not combined with other PB) was prescribed for 45.4 percent of patients, calcium carbonate (CaCO3) alone for 26.5 percent, sevelamer combined with CaCO3 for 2.1 percent and calcium acetate for 5.2 percent. Prescription of PB was noted in 53 percent of the patients with phosphorus <3.5 mg/dL and 40 percent with phosphorus <3.0 mg/dL. In disagreement with K/DOQI, prescription of calcitriol was found in 19 percent of patients with PTH<150 pg/mL and prescription was absent for approximately 35.4 percent with PTH>300 pg/dL combined with phosphorus equal or less than 5.5 mg/dL, calcium equal or less than 9.5 mg/dL and calcium x phosphorus product (CaxP)<55 mg2/dL2. For this latter group 38 percent had a prescription of sevelamer without other phosphate binders. CONCLUSION: Results show a large percentage of prescriptions of sevelamer among patients on maintenance hemodialysis in a Brazilian city, despite the high cost of the medication and absence of contraindications for PB with calcium salts. Results in patients with PTH<150 pg/mL and with PTH>300 pg/mL combined with certain concentrations of calcium, phosphate and CaxP also indicate the need to evaluate practices for use of phosphate binders and calcitriol.

Adesão ao tratamento farmacológico em pacientes com doença renal crônica / Medication compliance in patients with chronic kidney disease

Introdução: A não-adesão ao tratamento farmacológico prejudica o alcance dos resultados terapêuticos no retardo da progressão da doença renal crônica(DRC). O objetivo do presente estudo foi mensurar a prevalência da não-adesão ao tratamento farmacológico e avaliar os motivos apontados pelos pacientes para o comportamento não aderente. Método: Estudo transversal envolvendo 130 pacientes com DRC do ambulatório de nefrologia de um hospitaluniversitário, com idade média de 48,8 + 15,8 anos, em uso contínuo de algum medicamento anti-hipertensivo ou imunossupressor e que não estivessemsendo submetidos a qualquer terapia de substituição renal. A adesão foi mensurada através do método do auto-relato em uma entrevista com questionário. Foram considerados não aderentes pacientes que relataram ter ingerido menos de 80% dos comprimidos prescritos de pelo menos um medicamento. Foram coletados dados sociodemográficos, clínico-laboratoriais e os motivos alegados pelos pacientes para não aderir ao tratamento. Resultados: A prevalênciada não-adesão ao tratamento farmacológico foi de 18,5%. A falta de acesso aos medicamentos foi o motivo mais relatado pelos pacientes (54,5%) para a não-adesão. Não houve diferença estatisticamente significante entre a não-adesão ao tratamento com anti-hipertensivos e com imunossupressores.Discussão: Empregando o mesmo método, outros estudos encontraram prevalências de não-adesão ao tratamento da hipertensão e do diabetes variando entre 4% e 37,8%. Conclusões: Uma parcela significativa de pacientes estudados foi considerada não aderente ao tratamento farmacológico. A falta de acesso aos medicamentos permanece como uma causa de não-adesão, sugerindo a necessidade de melhorias na assistência farmacêutica.

Background: Medication noncompliance hinders the accomplishment of the therapeutic goals of delaying the progression of chronic kidney disease (CKD).The aim of the present study was to calculate the prevalence of medication noncompliance and to assess the reasons mentioned by the patients for theirnoncompliant behavior. Methods: A cross-sectional study was performed with 130 CKD patients from a nephrology outpatient university clinic, average age of 48.8 + 15.8 years old, continuously taking some self-administered antihypertensive or immunosuppressive drug and who were not on renal replacementtherapy. Noncompliance was measured through the self-reporting method (during an interview). Patients were considered noncompliant if they had taken less than 80% of the prescribed medication of any antihypertensive or immunosuppressive drug. Survey data showed sociodemographic, clinical, andlaboratorial characteristics and the reasons mentioned by the patients for their non-compliance. Results: Prevalence of medication noncompliance was 18.5%. Lack of access to medicine was the most commonly reported problem with medication use (54.5%). There was no statistically significant difference between the antihypertensive drug noncompliance and the immunosuppressive drug noncompliance. Discussion: Using the same method other studieshave reported prevalence of antihypertensive and hypoglycemic drug noncompliance ranging from 4 to 37.8%. Conclusions: A significant share of the studied patients was considered noncompliant to the pharmacotherapy. Lack of access to medicine remains as an important cause of medicationnoncompliance, suggesting the need for improvement in pharmaceutical assistance.

Blockade of renin-angiotensin-aldosterone system in kidney and heart disease: how much do we need?

The renin-angiotensin-aldosterone system (RAAS) plays a pivotal role in both cardiac and renal injury. Inhibition of RAAS with either an angiotensin converting enzyme inhibitor (ACE-I) or an angiotensin receptor blocker (ARB) provides both cardiac and renal protection, which is independent and additive to the benefit obtained from lowering blood pressure (BP). The combination of an ACE-I and an ARB should be used only for proteinuric renal disease and not for BP reduction. Patients with proteinuria >1 g/day despite optimal BP control with maximal dose of ACE-I or ARB monotherapy may benefit from a combination therapy. Inhibition of aldosterone with spironolactone or eplerenone provides survival advantage in patients with low LV ejection fraction and may also have antiproteinuric effects. Until further information is available, the routine combined use of all three inhibitors of the RAAS cannot be recommended.

Divergences in antihypertensive therapy in special situations in nephrology

CONTEXT AND OBJECTIVE: The choice of an antihypertensive drug is based on several criteria and specific situations give rise to doubt and controversy. The aim here was to evaluate physicians’ approaches towards treatment with antihypertensive agents in specific situations. DESIGN AND SETTING: Cross-sectional study, at Universidade Federal de São Paulo, São Paulo. METHODS: A questionnaire was applied during a nephrology meeting to evaluate individual approaches towards each hypothetical clinical situation. The questionnaire consisted of five multiple-choice questions (clinical cases) concerning controversial aspects of antihypertensive therapy. RESULTS: A total of 165 questionnaires were analyzed. Most participants were nephrologists (93.2 percent). There was a preference for angiotensin-converting enzyme (ACE) inhibitors in at least two of the cases. Only 57.2 percent of the physicians were correct in choosing beta-blockers as the first-line drugs for patients with ischemic coronary disease. Moreover, 66.2 percent chose ACE inhibitors as the first-line drugs for patients with chronic kidney disease and proteinuria. About 5 percent of the physicians did not follow the current recommendations for the use of ACE inhibitors in diabetic patients with microalbuminuria. The most controversial question concerned the first-line drug for advanced chronic kidney disease. Most physicians were correct in choosing calcium channel blockers and avoiding ACE inhibitors in renovascular hypertension in the case of a patient with a single functioning kidney. CONCLUSIONS: Most physicians adopted the correct approach, but some had an alternative strategy for the same situations that was not based on evidence.

CONTEXTO E OBJETIVO: A escolha da droga anti-hipertensiva depende de diversos fatores. Determinadas situações geram dúvida e discordância entre médicos. O objetivo foi avaliar a conduta de nefrologistas e clínicos em situações hipotéticas relacionadas ao tratamento da hipertensão. TIPO DE ESTUDO E LOCAL: Estudo transversal, na Universidade Federal de São Paulo, São Paulo, Brasil. MÉTODO: Foi aplicado um questionário com cinco casos clínicos hipotéticos durante o X Encontro Paulista de Nefrologia, com o objetivo de avaliar a primeira escolha de droga anti-hipertensiva em cada situação, contemplando as principais dúvidas relacionadas. RESULTADOS: Foram analisados 165 questionários. A maior parte dos médicos era composta por nefrologistas (93,2 por cento). Houve preferência pelo uso dos inibidores da enzima conversora de angiotensina (IECA) em dois dos cinco casos. Apenas 57,2 por cento acertaram na escolha do beta-bloqueador como primeira opção nos pacientes com coronariopatia. Além disso, 66,2 por cento optaram por IECA como drogas de eleição em renais crônicos com proteinúria. Aproximadamente 5 por cento dos colegas não seguiram as recomendações quanto ao uso dos IECA ou ARA em diabéticos com microalbuminúria. A questão com mais divergências foi a que avaliou a droga de escolha na doença renal crônica em fase avançada. A maior parte dos médicos acertou ao evitar o uso dos IECA na hipertensão renovascular em pacientes com rim único funcionante. CONCLUSÕES: A maior parte dos colegas adota condutas coerentes com os consensos relacionados à hipertensão arterial e doença renal, contudo, uma parcela não desprezível diverge e adota condutas não recomendadas.

Insuficiência renal crônica e hormônio de crescimento: efeitos no eixo GH-IGF e na leptina / Chronic renal failure and growth hormone: effects on GH-IGF axis and leptin

OBJETIVO: Avaliar as alterações de IGF-1, IGFBP-3, leptina e insulina após o uso de doses de reposição de hormônio de crescimento recombinante humano (rhGH) em crianças baixas pré-púberes com insuficiência renal crônica (IRC). CASUíSTICA E MÉTODOS: Em 11 crianças (3F:8M), com idade média de 9,6 anos, em uso de rhGH (0,23mg/Kg/semana) por 12 meses, foram dosados (antes, 6 e 12 meses após o início do tratamento com rhGH) leptina, insulina, glicemia, IGF-1 e IGFBP-3. RESULTADOS: As concentrações séricas de leptina, insulina e glicemia não variaram significativamente no decorrer do uso do rhGH, sendo observado o padrão de leptina e glicemia normais, com hiperinsulinemia. Houve aumento significativo da IGF-1 e IGFBP-3 durante o uso do rhGH. CONCLUSÕES: O uso de doses de reposição de rhGH durante 12 meses em um grupo selecionado de crianças com IRC propiciou aumento significativo da concentração sérica de IGF-1 e IGFBP-3, com leptinemia normal e resistência insulínica.

Estatinas na doença renal crônica / Statins in chronic renal disease

Hipertrigliceridemia e o HDL baixo são aspectos comuns em pacientes com insuficiência renal crônica. A mortalidade cardiovascular está substancialmente aumentada na presença de doença renal crônica (10-20 vezes maior). Existem evidências de estudos clínicos com estatinas sugerindo uma ação protetora dessas drogas na progressão da doença renal. Além disso, pacientes pós-transplante renal recebendo fluvastatina, experimentaram redução na incidência de infartos não fatais e de mortalidade cardíaca. Entretanto, um estudo recente com atorvastatina não demonstrou reduções na morbi-mortalidade cardiovascular entre pacientes diabéticos em hemodiálise. Estudos em andamento definirão o preciso papel das estatinas neste grupo especial de pacientes.

Growth hormone therapy.

Growth hormone (GH) therapy has revolutionized treatment of children with growth hormone deficiency (GHD). Improved height outcome with final height in the target height range has been achieved in these children. Identification of Creutzfeldt-Jakob disease, a deadly prion mediated disorder, in recipients of pituitary GH accelerated the transition from pituitary derived GH to recombinant GH. Once daily subcutaneous administration of the freeze-dried preparation at evening is the recommended mode of GH therapy. Studies have led to use of higher dose of GH for improving height outcome (0.33 mg/kg/week or 0.14 IU/kg/day) albeit at a significantly high cost. Growth velocity increases from 3-4 cm/year before therapy to 10-12 cm/year during the first two years of therapy and is maintained at 7-8 cm/year after a period of two years. Close follow-up with regular clinical and laboratory monitoring is essential for achieving a desirable height outcome. A theoretical unlimited supply has led to wide spread use of GH in a variety of disorders other than GHD. Initially started in children with Turner syndrome, GH has now been used in chronic renal failure, idiopathic short stature and intrauterine growth restriction besides a wide array of newly emerging indications.

Short stature and growth hormone.

Normal growth and development is a prime concern during childhood. Accurate assessment is essential for differentiating between normal and abnormal growth. Increased accessibility to growth hormone has equipped the pediatrician and pediatric endocrinologist to treat and improve growth in many clinical scenarios. At the same time, there is added responsibility to use this tool judiciously. This review summarizes the basics of proper growth assessment, differentiation of normal and abnormal growth causes of and works up of short stature, and delineation of indications for growth hormone treatment.

Angiotensin II AT1 Receptor Blockade Changes Expression of Renal Sodium Transporters in Rats with Chronic Renal Failure

We aimed to examine the effects of angiotensin II AT1 receptor blocker on the expression of major renal sodium transporters and aquaporin-2 (AQP2) in rats with chronic renal failure (CRF). During 2 wks after 5/6 nephrectomy or sham operation, both CRF rats (n=10) and sham-operated control rats (n=7) received a fixed amount of low sodium diet and had free access to water. CRF rats (n=10) were divided into two groups which were either candesartan-treated (CRF-C, n=4) or vehicletreated (CRF-V, n=6). Both CRF-C and CRF-V demonstrated azotemia, decreased GFR, polyuria, and decreased urine osmolality compared with sham-operated rats. When compared with CRF-V, CRF-C was associated with significantly higher BUN levels and lower remnant kidney weight. Semiquantitative immunoblotting demonstrated decreased AQP2 expression in both CRF-C (54% of control levels) and CRF-V (57%), whereas BSC-1 expression was increased in both CRF groups. Particularly, CRF-C was associated with higher BSC-1 expression (611%) compared with CRF-V (289%). In contrast, the expression of NHE3 (25%) and TSC (27%) was decreased in CRF-C, whereas no changes were observed in CRF-V. In conclusion, 1) candesartan treatment in an early phase of CRF is associated with decreased renal hypertrophy and increased BUN level; 2) decreased AQP2 level in CRF is likely to play a role in the decreased urine concentration, and the downregulation is not altered in response to candesartan treatment; 3) candesartan treatment decreases NHE3 and TSC expression; and 4) an increase of BSC-1 is prominent in candesartan-treated CRF rats, which could be associated with the increased delivery of sodium and water to the thick ascending limb.